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^£itUxtntt  Htbrarg 


THE 

INFLUENCE  OF  GROWTH 


ON 


CONGENITAL  AND  ACQUIRED 
DEFORMITIES 


By 

ADONIRAM   BROWN  JUDSON,  A.M.,  M.D. 

Orthopaedic    Surgeon    to    the    Out-Patient    Department,   New  York    Hospital, 

I  878-1903  ,   Statistical  Secretary  of  the  New  York  Academy  of  Medicine  ; 

formerly  Chairman   of  the   Orthopaedic  Section,  New  York  Academy 

of  Medicine ;   formerly    President   of  the   American    Orthopaedic 

Association  ;   Member  of  the  American  Medical  Association  j 

Fellow    of    the     American     Academy    of    Medicine  ; 

Formerly   Surgeon   U.  S.  Navy. 


PROFUSELY  ILLUSTRATED 


NEW  YORK 

WILLIAM  WOOD  AND  COMPANY 

MDCCCCV 


vh'^^ 


,  i'/  .  Copyright,  19  -    by 

'v  WILLIAM    WOOD    AND    COMPANY 


Zbie  asook  is  DeOicateD 

Tv.      lY   BROTHER, 

The   Rev.  Dr.  EDWARD   JUDSON, 

IN   AFFECTIONATE 

APPRECIATION   OF   HIS   GOOD   WORDS   AND 

BENEFICENT   DEEDS. 


411861 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/influenceofgrowtOOjuds 


PREFACE. 

The  original  intention  of  writing  a  paper  which 
should  call  attention  to  the  influence  of  growth  has 
led  to  the  preparation  of  this  book.  Certain  features 
have  been  included  which,  although  not  entirely- 
novel  in  themselves,  are  yet  presented  in  a  new  light 
which  gives  them  importance  as  matters  that  will 
repay  close  attention  in  practice.  Among  the  sub- 
jects thus  treated  are :  the  application  of  the  weight 
of  the  body  for  the  reduction  of  club-foot,  the  use 
of  the  equine  position  of  the  foot  to  increase  the 
length  of  a  shortened  limb,  the  adoption  of  symmet- 
rical movements  and  correct  rhythm  for  removing 
deformity  and  excluding  lameness,  and  the  manner 
in  which  misleading  tumors  are  produced  by  the  ro- 
tation of  lateral  curvature.  It  is  difficult  to  overlook 
entirely  the  element  of  growth  when  patients  are 
with  few  exceptions  children,  and  in  view  of  the  f:^ct 
that  the  word  orthopaedic  is  derived  from  two  Greek 
words  carrying  the  ideas  of  straightness  and  juvenile 
development.  A.  B.  Judson. 

New  York,  January,  1905. 


TABLE    OF    CONTENTS. 


PAGE 

Introduction 1-4 

CHAPTER   I. 

Congenital  Club-foot. 

Treatment  at  an  early  stage.— Mechanical  details.— Early  use  of 
adhesive  plaster.— Treatment  at  a  later  stage.—"  Stamping  a 
foot  straight."— Club-foot  of  spastic  contraction. — Neglected, 
relapsed,  and  inveterate  cases. — Subcutaneous  tenotomy. — 
Measurement  of  degrees  of  deformity.— Mechanical  disad- 
vantages of  the  human  foot.— Flat-foot. — Minor  ailments  of 
the  feet, 5-32 


CHAPTER    11. 

Deformities   Caused  by  Infantile  Paralysis. 

Exemption  of  the  upper  extremities.— Paralysis  of  thigh  muscles. — 
Of  leg  muscles. — Talipes  calcaneus.—"  The  Human  Wheel." 
— The  strain  on  the  tendo  Achillis.— Congenital  calcaneus. — 
Paralytic  varus. — Valgus. — Mechanics  of  locomotion. — De- 
formities of  locomotor  ataxia  and  Friedreich's  disease.— Im- 
portance of  treatment  during  growth. — ^Details  of  treatment. — 
Recognition  of  mechanical  surgery. — An  orthopaedic  labora- 
tory.— Apparatus  not  only  prosthetic,  but  also  preventive  and 
therapeutic  — Orthopaedic  surgery  as  a  specialty,         .         .  33-63 


viii  CONTENTS. 

CHAPTER    III. 
Tuberculous  Joint  Disease. 

PAGE 

An  affection  of  childhood. — Predisposing  causes. — Operative  and 
mechanical  treatment. — Intelligent  expectation. — Deformity. 
—Fear  of  ankylosis. — favorable  outcome  depending  largely 
on  early  diagnosis,  ........  64-72 

CHAPTER    IV. 

White  Swelling  of  the  Knee. 

Removal  of  bodily  weight  imperative. — By  recumbency. — By  ax- 
illary crutches. — By  ischiatic  support. — Arrest  of  motion  by 
leverage  of  pressure  and  counter-pressure.  — Deformity  re- 
duced by  the  same  instrument. — Ultimate  mobility  compro- 
mised by  unreasonable  fear  of  ankylosis.— Treatment 
throughout  the  growing  period. — Subluxation. — Abscesses.— 
Knock-knee. — Bow-legs. — Ankle  disease,     ....  73-86 

CHAPTER   V. 

Treatment  of  Hip  Disease. 

Basis  of  mechanical  treatment. — Historical  notes.— Use  of  adhe- 
sive plaster  for  traction. — Practical  inferences  from  morbid 
anatomy.— Correlation  of  traction  and  fixation. — The  Ameri- 
can splint. — Details  of  application  in  the  third  stage. — Weight 
and  pulley. — Paradox  in  treatment  of  hip  disease  and  frac- 
ture.— Ultimate  mobility  promoted  by  fixation. — Management 
of  apparatus  at  home. — Joint  disease  in  the  upper  and  lower 
limbs. — Weight  of  the  body  as  a  factor. — Comparative  im- 
portance of  traction  and  protection. — Tuberculous  disease  of 
wrist,  elbows  and  shoulder. — The  ischiatic  crutch. ^ — Its  use 
as  an  artificial  limb. — In  ununited  fracture. — Discontinuing 
treatment. — Overexertion  to  be  avoided  after  recovery,      .  S7-129 


CONTENTS.  ix 

CHAPTER   VI. 

Abscesses  of  Hip  Disease. 

PAGE 

Absorbed,  cold,  and  inflamed  abscesses.— Without  effect  on  dura- 
tion and  results  of  disease. — Tiieir  origin,  significance,  and 
deportment.  — Location  of  sinuses. — Question  of  operation 
or  expectation, 130-141 

CHAPTER   VII. 

Diagnosis,  Prognosis,  and  Appreciation  of  Results 
OF  Hip  Disease. 

Symptoms  and  signs. — Refiex  action  the  most  valuable  early  sign. 
— Three  diagnostic  signs  of  established  disease. — To  test  for 
antero-posterior  and  lateral  mobility. — Structural  shorten- 
ing.—Found  also  in  acute  epiphysitis,  diastasis,  infantile 
paralysis,  congenital  dislocation,  and  coxa  vara.— The  syno- 
vitis of  continued  fever.— Good  results  depending  largely  on 
diagnosis  before  pain  appears. — Good  functional  results  after 
the  third  stage. — Amount  of  motion  less  important  than  posi- 
tion of  limb. — Manikin  demonstrations. — The  goniometer. — 
Ready  methods  of  estimating  shortening,         .         .         .  142-169 


CHAPTER   VIII. 

Causes  and  Prevention  of  the  Deformity  of  Hip 
Disease. 

'  Real  "  less  important  than  "  apparent  "  shortening. — Faulty  po- 
sition of  the  limb. — Fixation  the  result  at  first  of  muscular 
contraction,  afterward  of  ankylosis.— The  neuro-muscular 
element. — The  movable-immovable  joint. — Faulty  position 
unconsciously  assumed  for  convenience. — Method  of  induc- 
ing its  surrender. — Illustrations  of  favorable  and  unfavorable 
results.- Difficulty  of  direct    mechanical  reduction. — Over- 


CONTENTS. 

PAGE 

coming  structural  shortening. — Local  hyperaemia  and  anae- 
mia.— Extension  shoe.— Equine  foot. — Definition  of  lameness 
in  general. — Normal  and  abnormal  rhythm. — Influence  of 
growth  on  correction  of  deformity,     .....   170-188 


CHAPTER    IX. 

Pott's  Disease  of  the  Spine. 

A  disease  of  childhood,  but  occurring  also  in  the  aged. — Signs 
and  symptoms. — Local  pain  and  disabihty  often  absent. — 
Varying  effects  of  cervical,  lumbar,  and  dorsal  disease. — 
Compensating  lordosis. — To  make  a  diagnosis  before  appear- 
ance of  deformity. — Recovery  through  reaction  and  consoli- 
dation.— Recumbency. — Mechanical  support. — Arrest  of  mo- 
tion.— Transference  of  weight. — Incidental  improvement  of 
figure  during  growth.— A  practical  rule  and  mechanical  de- 
tails. —  Plaster-of-Paris  jacket.  —  Abscesses. —  Paraplegia. — 
Reduction  of  stature. — Caries  of  sternum,        .         .         .  189-216 


CHAPTER   X. 

Lateral  Curvature  of  the  Spine. 

Rotation. — Its  cause. — Its  effect  on  torso  overlooked  in  art. — 
Diagnosis  obvious,  but  incidental  effects  of  rotation  not 
always  recognized. — Tumors. — Sciatica. — Sacro-iliac  disease. 
—General  health  and  ability  not  compromised. — Rotating 
curvature  a  physiological  manoeuvre.— Incidental  and  typical 
curvatures. — Importance  of  treatment. — Braces. — Treatment 
based  on  clinical  observations. — Recumbency,  suspension, 
rest,  chest  expansion. — Sequence  of  causes,     .         .         .  217-244 


THE  INFLUENCE  OF  GROWTH 


UPON 


Congenital  and  Acquired  Deformities, 


INTRODUCTION. 

I  VENTURE  to  present  to  the  reader  a  new  volume 
on  orthopaedic  subjects,  not  because  there  is  any  lack 
of  excellent  systems  and  text-books,  but  rather  to 
emphasize  what  seems  to  lie  at  the  base  of  practice  in 
this  specialty,  the  fact  that  prevention  and  cure  are 
to  be  iOund  in  so  managing  a  case  and  equipping  a 
patient  that  natural  growth  will  be  the  principal 
factor  in  recovery.  Mr.  Hilton  said:  "  Repair  is  but 
the  repetition  of  growth.  The  same  elements,  the 
same  kindred  conditions  are  necessary  to  the  same 
results."  This  view  is  far  from  including  all  there 
is  in  orthopaedic  practice,  but  the  thought  thus  ex- 
pressed should  temper  the  consideration  of  all  pro- 
cedures, whether  operative  or  mechanical,  which 
have  for  their  object  the  removal  of  deformity. 

The  average  length  of  a  new-born  baby  is  nineteen 
and  a  half  or  twentv  inches.      During  the  first  six 


2  GROWTH  AND  DEFORMITY. 

months  he  grows  from  four  to  live  inches,  and  in  the 
second  six  months  from  three  to  four  inches.  Dur 
ing  the  second  year  he  grows  from  three  to  five 
inches;  during  the  third  year  from  two  to  three 
inches  and  a  half ;  and  during  the  fourth  year  from 
two  to  three  inches.  By  the  end  of  the  fifth  year  the 
child  has  generally  doubled  his  original  length.  After 
that  his  average  annual  growth  is  from  one  inch  and 
two-thirds  to  two  inches,  with  a  slight  acceleration  in 
the  years  just  preceding  puberty.  This  period  of 
gradual  increase  in  size,  covering  nearly  a  quarter  of 
the  three  score  years  and  ten,  may  not  be  neglected 
in  intelligent  efforts  to  banish  deformity  and  promote 
physical  ability,  refreshing  the  significance  of  Andry's 
designation  of  orthopaedic  surgery  as  the  "art  of 
making  a  child  grow  straight."  If  the  surmise  is 
correct  that  the  rate  of  growth  is  not  uniform  from 
year  to  year,  but  is  now  rapid  and  again  slow,  it 
would  be  well  if  fluctuations  in  the  rate  could  be  rec- 
ognized or  foreseen,  making  possible  especial  ortho- 
paedic efforts  when  growth  is  rapid  and  comparative 
relaxation  of  treatment  when  it  is  progressing  more 
slowly. 

The  methods  of  diagnosis,  prevention,  and  treat- 
ment herein  presented  are  put  on  record  as  having 
proved  useful  and  as  likely  to  be  at  least  suggestive 
in  the  practice  of  others.  These  pages  probably 
contain  very  little  that  is  new  or  presented  for  the 


INTRODUCTION.  3 

first  time.  So-called  new  observations  and  inventions 
in  medicine  and  surgery  have  generally  been  made 
before  and  recorded  on  some  page  which  for  some 
reason  or  other  has  not  been  read.  In  regard  to 
"  new  truths,"  it  has  been  wittily  said  that  *'  what  is 
true  is  not  new  and  what  is  new  is  not  true."  In  all 
departments  of  industry  improvements  are  planned 
some  time  before  they  are  realized  or  tested,  because 
unfavorable  conditions  have  to  be  first  changed  by 
improvements  in  other  departments.  Imagination 
walks  ever  in  front  of  the  advancing  line  of  the  arts 
and  sciences,  and  no  member  of  the  band  may  pro- 
gress except  in  company  with  the  rest.  In  orthopae- 
dic surgery  methods  have  improved,  not  because 
something  new  has  been  learned  about  disease  and 
principles  of  treatment,  but  rather  because  general 
knowledge  has  increased  and  difficult  mechanical 
effects  have  become  convenient  through  improve- 
ments in  and  novel  applications  of  such  materials  as 
adhesive  plaster,  gypsum,  and  steel.  The  fine  ad- 
justments which  Fayette  Taylor  made  by  ingeniously 
constructed  joints  in  his  "  spinal  assistant "  are  now 
more  readily  made  in  Bessemer  steel.  Conditions  of 
advance  are  not  only  physical,  but  are  also  found  in 
mental  attitudes  which  are  liable  to  change  in  re- 
sponse to  reason  and  experience.  When  the  fear  of 
wounding  a  tendon  was  overcome,  subcutaneous 
tenotomy  was  accepted.     The  fear  of  ankylosis  may 


4  GROWTH  AND  DEFORMITY. 

in  course  of  time  subside,  and  the  views  of  the  surgi- 
cal world  may  in  due  order  turn  in  favor  of  intelli- 
gent expectation  in  the  management  of  joint  diseases, 
thus  making  good  Mr.  Hilton's  additional  words: 
"  Rest  is  the  necessary  antecedent  to  the  accomplish- 
ment of  repair  and  growth.  This  is  surely  the  natu- 
ral suggestion  of  a  means  toward  an  end  which 
should  never  be  lost  sight  of  by  the  physician  or 
surgeon." 


CHAPTER    I. 

CONGENITAL    CLUB-FOOT. 

The  effect  of  natural  growth  on  deformity  is  very 
evident  in  a  case  of  congenital  club-foot.  A  baby 
gains  in  length  from  seven  to  nine  inches  in  the  first 
year,  in  which  period  the  deformity  becomes  more 
obvious  and  obstinate  with  each  added  month ;  but 
if  the  foot  is  held  in  a  good  position,  growth  intro- 
duces symmetry  and  facilitates  restoration. 

TREATMENT   AT   AN    EARLY    STAGE. 

This  deformity  cannot  receive  attention  too  early. 
Dr.  Willard  says :  "  The  time  for  beginning  the 
treatment  of  congenital  club-foot  is  at  the  hour  of 
birth."  The  limb  should  at  once  begin  to  grow 
straight  instead  of  growing  crooked.  Ready  to  yield, 
the  little  foot  seems  to  be  held  out  in  an  appeal  for 
the  application  of  a  lever,  making  points  of  pressure 
and  counter-pressure  in  the  directions  indicated  by 
the  arrows  in  Figs,  i,  2,  3,  and  4.  A  plaster-of-Paris 
dressing  observes  the  same  points  of  action.  The 
brace  shown  in  Figs.  3  and  4  may  be  made  of  brass 
or  other  convenient  metal.     The  thin  discs  are  softly 


GROWTH  AND  DEFORMITY. 


padded.  The  brace  is  applied  with  three  strips  of 
adhesive  plaster  and  very  gradually  bent  to  differ- 
ent shapes,  as  seen  in  Figs.  5,  6,  7,  and  8,  the  foot 
taking  on  corresponding  shapes  until  it  occupies  the 
concavity  of  the  brace  where  valgus  is  seen  instead 


^ 


Fig.  I. 


Fig.  2. 


Fig. 


Fig.  4. 


% 


Fig.  5. 


Fig.  6. 


Fig.  7. 


Fig.  8. 


Figs.  i-8. — Points  of  Pressure  and  Counter-pressure  in  the  Early  Stage  of 
Treatment,  and  Changes  made  in  the  Brace  and  in  the  Shape  of  the 
Foot. 

of  varus.  These  successive  changes  took  place  and 
were  carried  farther  in  Case  I.,  as  is  shown  in  Fig. 
22,  on  page  22.  Correction  cannot  well  be  overdone 
in  this  stage.  The  details  of  this  application  are  pre- 
sented more  clearly  in  Fig.  9,  which  shows  the  right 
foot  of  a  boy  six  months  old  in  process  of  correction. 


CONG  EN  I TA  L    CL  UB-FO  O  T. 


The  plaster  surrounding  the  leg  and  the  upper  shield 
and  that  surrounding  the  foot  and  the  lower  shield 
are  lightly  applied  as  they  simply  hold  the  apparatus 
in  place.  The  middle  plaster,  after  being  securely 
fastened  by  several  turns 
around  the  upright,  re- 
ceives the  unattached 
middle  shield  and  sur- 
rounds the  lower  part  of 
the  leg  and  the  brace. 
While  one  hand  reduces 
deformity  by  forcing  the 
limb  and  brace  together, 
let  the  other  hand  secure 
the  middle  plaster  after 
repeatedly  carrying  it 
around  the  limb  and  the 
upright  of  the  brace, 
being  ever  mindful  of 
the  pressure  made  by 
the  middle  shield,  which 
is  the  key  to  the  application.  It  is  needless  to  say 
that  careful  attention  is  required  to  secure  comfort 
and  efficiency,  which  follow  the  skill  born  of  repeti- 
tion. Under  advice  and  instruction  the  successful 
carrying  out  of  the  necessary  details  depends  on  the 
intelligence  found  in  the  patient's  home.  Reduction 
is  assisted  by  the  position  of  the  babe  "  in  arms," 


Fig.  g. — Details  of  Application. 


8  GROWTH  AND  DEFORMITY. 

where  no  part  of  his  weight  interferes  with  the  me- 
chanical force  used.  One  or  two  days  in  each  week 
may  be  given  to  freedom  of  the  foot  and  manipula- 
tion in  order  to  maintain  flexibility.  Without  haste, 
violence,  or  pain,  the  foot,  having  doubled  its  size 
by  growth,  will  be  found  valgus  when  resting  undis- 
turbed, and  the  tendo  Achillis,  as  an  incidental  effect 
and  without  especial  attention,  will  be  sufficiently 
lengthened  to  permit  a  right-angled  position  of  the 
foot.  This,  the  first  stage  of  treatment,  should  be 
concluded  long  before  walking  begins. 

Early  Use  of  Adhesive  Plaster.— In  the  case  of  a 
new-born  babe,  before  a  brace  can  be  prepared,  the 
trouble  may  be  met  by  surrounding  the  foot  with 
a  strip  of  adhesive  plaster  in  such  a  manner  as  partly 
to  correct  deformity,  the  improved  position  being 
secured  by  making  firm  traction  on  the  long  end  of 
the  plaster  and  attaching  it  to  the  outer  side  of  the 
leg.  This  method  was  advocated  in  1850  by  Dr.  S. 
D.  Gross,  at  that  time  one  of  the  faculty  of  the  New 
York  University.  The  same  material  had,  however, 
been  used,  although  in  a  different  way,  many  years 
before  in  the  treatment  of  this  affection.  In  1740 
Mr.  Cheselden  wrote :  "  The  first  knowledge  I  had 
of  a  cure  of  this  disease  was  from  a  professed  bone- 
setter.  I  recommended  the  patient  to  him,  not 
knowing  how  to  cure  him  myself.  His  way  was  by 
holding  the  foot  as  near  the  natural  position  as  he 


CONGENITAL    CLUB-FOOT.  g 

could  and  then  rolling  it  up  with  strips  of  sticking 
plaster,  which  he  repeated  from  time  to  time  as  he 
saw  occasion,  until  the  liml^  was  restored  to  a  normal 
position."  In  orthopaedic  practice  the  material  or 
method  is  often  of  less  importance  than  the  skill  and 
enthusiasm  of  the  physician.  If  he  has  invented  or 
improved  an  instrument,  the  attendants  of  the  pa- 
tient, inspired  by  his  confidence,  unite  with  him  in 
overcoming  the  inconvenience  and  trouble  insepa- 
rable from  mechanical  treatment  and  thus  succeed 
where  others  meet  with  disappointment. 

TREATMENT   AT   A    LATER    STAGE. 

When  the  patient,  with  his  foot  now  in  good  shape, 
learns  to  walk  a  critical  stage  of  treatment  begins. 
If  left  to  itself  the  foot  will  relapse  at  once  under  the 
weight  of  the  body,  which  develops  a  distinct  bound- 
ary plane  dividing  varus  from  valgus  as  the  foot 
presses  the  ground.  By  way  of  illustration,  place  the 
ulnar  border  of  the  hand  on  a  table  and  it  will  be 
seen  that  pressure,  with  alternations  of  pronation  and 
supination,  will  in  turn  produce  full  pronation,  cor- 
responding with  valgus  in  the  foot,  and  full  supina- 
tion, corresponding  with  varus.  Applying  pressure 
equal  to  twenty-five  pounds  brings  to  light  the  fact 
that  the  weight  of  a  child  will,  if  properly  directed, 
insure  a  normal  foot,  or  if  misdirected  confirm  de- 


10 


GROWTH  AND  DEFORMITY. 


formity.  Advantage  of  this  may  be  taken  by  the 
use  of  a  brace  that  holds  the  foot,  even  a  httle,  on 
the  right  side  of  the  plane  between  varus  and  valgus. 


Fig.  io.— Flexible  Para- 
lytic Club-foot  of  the 
Patient  seen  in  Fig.  17 
(p.  14). 


Fig.  II. — Brace  for  Foot 
shown  in  Fig.  10. 


The  child  may  thus,  with  increasing  weight  and  ac- 
tivity, achieve  recovery  by  stamping  the  foot  straight. 
Fig.  10  shows  the  deformed  but  flexible  foot  of  a 
child  four  years  old.  The  brace  used  in  this  case  is 
shown  in  Fig.  ii.  Its  weight  is  thirteen  ounces.  It 
is  made  of  soft  steel  and  has  a  band,  an  upright,  and 


CONGENITAL    CL UJU'OOT. 


II 


a  foot-piece  composed  of  a  tread  and  a  riser.  The 
foot-piece  is  lined  with  adhesive  plaster  to  prevent 
rust  and  a  piece  of  truss  leather  fastened  with  two 
copper  rivets.  More  or  less  valgous  in  shape,  the 
instrument  makes  pressure  on  the  outer  side  of  the 
ankle,  while  counter-pressure  on  the  inner  side  is 
found  at  the  upper  part  of  the  brace  and  along  the 
riser  of  the  foot-piece.  The  sole  of  the  foot  finds  on 
the  tread  an  inclined  surface  like  that  of  the  inner 
side  of  the  sole  of  a  shoe  whose  outer  border  has 
been  thickened  in  order  to  precipitate  valgus,  an 
effect  which  is  seen  in  Fig.  12.  This 
favors  the  leverage  by  which  the  foot 
is  held  on  the  right  side  of  the  plane. 

Dr.  Cook  ingeniously  sought  to 
combat  varus  by  providing  the  sole  of 
a  common  shoe  with  an  ample  steel 
extension  directed  outward  in  order 
to  reduce  deformity  with  the  descent 
of  the  body,  in  imitation  of  the  method 
by  which  quadrupedal  gait  is  modified 
by  the  application  of  a  horseshoe  forged 
with  a  lateral  or  antero-posterior  ex- 
tension. His  experience  proved  that 
such  an  application  would  probably  be 
more  effective  in  club-foot  if  a  coali- 
tion were  practicable  between  the  foot  and  shoe,  such 
as  is  found  in  veterinary  practice. 


Fig.  12.  —  Tread 
of  Brace  with  the 
effect  of  a  Built- 
up  Sole  (1S92). 


12  GROWTH  AND  DEFORMITY. 

The  upright  of  the  brace  may  be  inchned  back- 
ward ten  or  fifteen  degrees  with  a  corresponding  ex- 
tension of  the  foot.  This  increases  the  length  of  the 
lever  applied  against  deformity.  Thus  arranged,  the 
tread  will  cut  the  sole  of  the  shoe,  which  may  be  pro- 
tected by  a  steel  in-sole  (about  an  inch  wide)  lying  be- 
tween the  brace  and  the  shoe,  or  else  cut  to  fit  the  an- 
terior part  of  the  sole  and  fastened  inside  the  shoe  by 
a  screw.  The  strap  which  spans  the  front  of  the  leg 
carries  a  sliding  pad  to  allay  the  friction  transferred 

to  this    point  from  the  toe, 
as  in  the  treatment  of  talipes 
calcaneus   (p.  47).     This   ar- 
\     rangement  is  otherwise  use- 
ful in  relieving  the  front  part 
Fig.  13.— Adhesive  Strip  Ap-     of  the  foot  from  part  of  the 
plied  to  Untwist  Anterior     weight   of   the   body,   which 

Part  of  Foot  (1887).  .  ,  ... 

seriously  mterferes  with  the 
correction  of  deformity.  It  also  seems  to  have  an  en- 
tirely unexpected  tendency  to  lengthen  the  heel  cord. 
The  action  of  the  brace  may  be  improved  by  the 
use  of  adhesive  plaster  applied  as  in  Fig.  13,  a  strip 
encircHng  the  foot  and  buckled  to  the  riser  at  A ;  or 
a  window,  D,  may  be  cut  in  the  junction  of  the  tread 
and  riser,  as  seen  in  Fig.  14,  through  which  the  plas- 
ter C,  passes  to  the  buckle  7%  on  the  under  side  of 
the  tread.  The  plaster  may  be  conveniently  doubled, 
as  at  A  in  Fig.  15,  the  remainder  of  the  facing,  B^ 


CONGENITA  L    CL  UB-FOO  T. 


13 


being  removed  at  the  time  of  application.  The  pre- 
hension and  traction  made  by  this  material  admir- 
ably imitate  the  action  of  the  hand,  making  pressure 


Fig.  14. — Window  for  Exit  of  Adhesive  Strip  (1896) . 

in  the  selected  directions,  untwisting  the  anterior 
part  of  the  foot  and  keeping  the  toes  from  surmount- 
ing the  riser. 

Fig.  16  shows  the  brace  applied  to  the  foot,  and 
Fig.  17  the  child  equipped  for  stamping  her  foot 
straight,  increasing  activit}'  and  weight  and  juvenile 
growth  combining  to  secure  a  good  result.     Applied 


Fig. 


-Adhesive  vStrip  Ready  for  Application. 


under  or  over  the  stocking,  the  brace  is  worn  incon- 
spicuously and  without  inconvenience  for  many 
months,  a  larger  one  being  made  when  required  by 


14 


GROWTH  AND  DEFORMITY. 


the  patient's  growth,  which  being  rapid  at  this  age  is 
a  welcome  ally.  By  the  end  of  the  fifth  year  a  child 
has  doubled  his  original  length,  an  increment  that 
has  perforce  a  positive  effect  for  benefit  or  injury. 


Fig.  1 6, — Brace  seen  in  Fig.  ii, 
Applied  to  Foot  seen  in  Fig.  lo. 


Fig.  17. — Brace  Applied 
and  Foot  Dressed. 


Nothing  especial  is  needed  in  the  way  of  shoes,  the 
mate  of  the  other  shoe  answering  every  purpose.  If 
necessary  the  capacity  of  the  shoe  may  be  increased 
by  cutting  it  down  in  front  and  adding  more  eyelet 
holes.  With  this  instrument  treatment  may  be  con- 
cluded.    The  result  should  be  normal  ability,  prac- 


CONGENITAL    CLUB-FOOT.  15 

tically  not  impaired  l^y  a  lied  cord  somewhat  shorter 
than  normal.  This  tendon  with  the  other  fibrous 
structures  would  doubtless  yield  to  direct  me- 
chanical treatment,  but  it  is  found  to  adapt  its 
length  to  the  requirements  of  walking  and  run- 
ning without  especial  attention  in  the  course  of 
treatment. 

Inversion,  commonly  seen  at  an  early  stage,  may 
not  cause  anxiety  as  it  takes  place  at  the  hip,  and 
disappears  under  instruction  when  the  child  learns, 
in  due  time,  the  necessity  of  making  a  good  appear- 
ance. Parental  impatience  sometimes  leads  to  ces- 
sation of  treatment  after  the  brace  has  been  worn 
for  several  months  with  apparently  full  recovery; 
but  when  a  relapse  to  varus  is  indicated  by  the  re- 
appearance of  a  callus  and  the  rapid  wearing  through 
of  the  outer  border  of  the  sole  of  the  shoe,  treatment 
is  necessarily  resumed  for  another  period.  Success 
implies  perhaps  uncommon  intelligence  in  the  par- 
ents, who  should  possess  the  difficult  quality  of  pa- 
tience and  be  able  to  give  appreciative  attention  to 
the  case  at  home.  On  the  other  hand  the  surgeon 
has  no  easy  task  who  makes  the  frequent  necessary 
mechanical  adjustments  and  cannot  escape  ultimate 
responsibility  for  the  home  management. 

The  Cliib-foot  of  Spastic  ConU^action. — Correction 
of  deformity  by  the  weight  of  the  body  properly  di- 
rected is  illustrated  in  the  equino-varus  seen  in  a  case 


i6  GROWTH  AND  DEFORMITY. 

of  spastic  contraction.  The  muscles  being  readily 
overcome  by  continuous  leverage,  the  corporal 
weight  holds  the  foot  in  the  normal  position,  which 
continues  when  the  brace  is  laid  aside  after  a  period 
of  treatment  in  which  growth  has  made  some  prog- 
ress. A  patient  thus  aided  to  walk  enjoys  a  general 
improvement  which  seems  to  react  favorably  on  the 
nervous  disorder. 


NEGLECTED,     RELAPSED,   AND    INVETERATE 
CLUB-FOOT. 

While  it  is  thus  easy  to  remedy  congenital  club- 
foot when  taken  early  and  treated  systematically 
there  is  great  difficulty  in  the  restoration  of  neg- 
lected, relapsed,  or  inveterate  cases,  of  either  con- 
genital or  acquired  origin.  Operative  treatment  is 
necessary  in  nearly  every  case  of  this  kind,  and  judg- 
ment will  be  required  lest  an  improvement  in  ap- 
pearance is  gained  at  the  expense  of  locomotor 
ability,  which  is  good  in  many  cases  even  of  severe 
deformity.  Bradford  and  Lovett's  treatise  records 
the  surprising  locomotor  skill  and  agility  acquired  in 
certain  cases  in  which  deformity  had  gone  uncor- 
rected. A  moderately  severe  resistant  club-foot  is 
seen  in  Fig.  i8.  In  such  a  case  the  application  of  a 
brace  which  forcibly  holds  the  varus  partly  corrected 
gives  excellent  ability  in  walking  and  running,  and  is 


CONGENITAL    CLUB-FOOT.  17 

often  and  very  excusably  preferred  by  the  youthful 
patient  to  an  operation  which  would  lessen  the 
strength  and  ability  of  the  foot,  although  improving 
its  appearance.  Worn  in  this  way  the  brace  is  a 
purely  prosthetic  appliance.  Its  effect 
would,  however,  be  therapeutic  and  ul- 
timately curative  if  the  patient  could 
be  induced  to  relieve  the  foot  from  the 
weight  of  the  body  by  wearing  in  ad- 
dition a  pair  of  crutches  or  an  ischiatic 
support  for  the  time  necessary  to  bring 
the  foot  around  to  that  position  in  which 
the  weight  of  the  body  would  assist  in 
completing  the  reduction  of  the  de- 
formity.    It  is  of  course  far  better  to  ^       „ 

Fig.   18. — Resis- 

foresee  these  troubles  in  the  very  early      tant  Paralytic 
youth  of  the  patient  when  complete  res-      ^lub-foot,  Age 

Ten  \ears. 

toration  is  easily  practicable. 

Dottble  Club-foot. — The  recumbent  position  is  nec- 
essary if  the  affection  is  double,  unless  one  limb  be 
treated  at  a  time,  in  which  case — as  when  only  one 
foot  is  affected— resort  may  be  had  to  crutches,  or, 
better,  to  ischiatic  support,  with  a  high  sole  under 
the  other  foot,  as  in  hip  or  knee  disease,  until  the 
straightening  of  the  brace  and  the  foot  and  contin- 
uous leverage  lead  the  way  to  the  vantage-ground 
where  the  weight  of  the  body  may  be  enlisted  as  a 
corrective  force. 


i8 


GROWTH  AND  DEFORMITY. 


Subcutaneous  Tenotomy.— If  the  tendo  Achillis 
fails  to  meet  the  requirements  of  locomotion  after 
reduction  of  deformity  by  this  method,  as  a  last  re- 


maining defect  it  may  be  divided.  In  1831  Dr.  Stro- 
meyer  (1804-76)  made  his  first  section  of  this  tendon, 
an  operation  which  has  been  said  to  "  mark  the 
beginning  of  the  whole  system  of  subcutaneous  sur- 


CONGENI TA  L    CL  UB-FOO  T. 


19 


gery  and  of  all  really  successful  orthopaedic  treat- 
ment." Five  years  later  Dr.  Little  (1810-94)  visited 
Stromeyer  and  against  the  advice  of  friendly  medi- 


FiG.  20. 


cal  authority  submitted  to  tenotomy  for  talipes  equi- 
no-varus  (left),  following  an  attack  of  infantile  paraly- 
sis at  the  age  of  four  years.  The  result  in  this  and 
other  cases  "  caused  a  revulsion  of  feeling  in  favor  of 
subcutaneous  tenotomy,"  which  was  first  performed  in 


20 


GROWTH  AND  DEFORMITY. 


England  by  Dr.  Little  himself  in  1837.  In  that  year 
Dr.  Detmold  (1808-94),  coming  to  New  York,  "  intro- 
duced orthopaedic  surgery  into  America,"  making  one 
hundred  and  eighty  divisions  of  the  heel  cord  in  two 


Fig.  21. 


years.  In  current  medical  opinion  Stromeyer  is 
credited  with  the  disco^'ery  of  subcutaneous  te- 
notomy, Little  with  having  widely  disseminated  a 
knowledge  of  it,  and  Detmold  with  its  introduction 


CONGENITAL    CLUB-FOOT.  21 

into  this  country.  Not  a  few  of  the  advances  of  sur- 
gery have  been  clue  to  pre\'ious  niisconceptions  of 
the  danger  of  invading  certain  regions  or  wounding 
certain  tissues.  Stromeyer's  discovery  greatly  en- 
couraged the  study  and  practice  of  orthopaedic  sur- 
gery. With  furtlier  advances  in  general  medicine  and 
surgery  it  is  probable  that  other  changes  of  mental 
attitude  will  be  seen  and  other  modifications  will  be 
accepted  in  the  methods  of  this  branch  of  practice. 

T/ie  Goniometer. — The  flexion  of  the  foot  on  the 
leg  may  be  conveniently  measured  by  the  goni- 
ometer. With  the  knee  flexed  in  order  to  relax  the 
gastrocnemii  and  the  tendo  Achillis,  and  the  foot 
held  midway  between  varus  and  valgus,  one  arm  of 
the  instrument  may  be  held  parallel  with  the  crest 
of  the  tibia,  and  the  other  with  the  plantar  surfaces 
of  the  heel  and  the  ball  of  the  foot.  The  degrees  of 
flexion  may  then  be  read  on  the  scale.  After  club- 
foot it  is  difficult  without  impairing  the  power  of  the 
limb  to  give  to  the  heel  cord  the  length  W'hich  nor- 
mally permits  flexion  of  fifty  or  sixty  degrees.  But 
flexion  of  twenty  or  twenty-five  degrees,  which  is  ac- 
quired in  the  course  of  routine  treatment,  practically 
secures  full  ability  without  defect  of  gait. 

Case  I. — Double  Congenital  Club-foot. — Without 
previous  attention,  treatment  was  begun  September 
5th,  1896,  at  the  age  of  three  months,  the  shape  of  the 
boy's  feet  at  that  age  being  seen  in  Fig.  22,  which 


22 


GROWTH  AND  DEFORMITY. 


also  shows  the  progress  made  in  the  case  until  the 
child  was  five  years  old.  The  natural  increase  in 
size  was  clearly  an  important  element  in  correction. 


Fig.  22.  — Case  I.   Reduction  Begun  by  Leverage,  Promoted  by  the  Favor- 
able Action  of  the  Weight  of  Body,  and  Aided  by  Growth. 

The  outlines  were  grouped  and  reduced  en  bloc  in 
the  camera  and  were  thus  made  to  present  their  rela- 
tive proportions.  The  first  stage  of  treatment  occu- 
pied twelve  months,  in  which  forty-three  visits  were 
made  to  the  office.  The  appearance  and  lateral 
flexibility  being   normal,  treatment   was   then    sus- 


CONGENITA L    CL  UB-FOO T. 


23 


pended.  At  the  end  of  five  months,  in  which  noth- 
ing was  done,  the  child  had  learned  to  walk,  and  it 
was  noticed  that  the  outer  borders  of  the  soles  were 
becoming  callous.  Braces  were  therefore  applied 
like  the  one  seen  in  Fig.  11,  larger  ones  being  sub- 
stituted as  the  child  grew.  In  this  stage  forty-two 
visits  were   made  in   twenty-two  months,  and  treat- 


FiG.  23. — Case  I.,  Corrected  Double  Congenital  Club-foot.     Age  of 
patient,  seven  years. 


ment  finally  ceased  when  the  patient  was  four  years 
old.  A  year  later  the  last  outlines  seen  in  Fig.  22 
were  taken.     At  that  time  the  left  ankle  was  flexible 


24 


GROWTH  AND  DEFORMITY. 


twenty-five  degrees,  and  the  right  thirty  degrees. 
When  walking  or  running  the  boy  had  no  defect  in 
his  gait.     Two  years  later  calluses  were  absent  and. 


Fig.  24. — Case  I.,  Corrected  Double  Congenital  Club-foot. 

the  toes  were  not  inverted  in  walking.  The  limbs  are 
seen  in  Figs.  23,  24,  and  25.  He  was  doing  what  other 
boys  of  his  age  do,  with  no  indication  that  his  feet  had 
ever  required  especial  attention. 

An  operation  is  often  a  desirable  resort  in  club- 
foot. Some  visits  to  the  physician  may  thus  be 
escaped.  The  statement  that  to  operate  for  club- 
foot is  a  confession  of  failure  is  too  sweeping.     Oper- 


CONG  EN  I TA  L    CL  UB-FOO  T. 


25 


ations  must,  however,  be  supplemented  l^y  mechani- 
cal treatment. 

A  general  view  of  the  sul^ject  shows  that  congeni- 
tal club-foot,  being  an  affection  easily  responsive  to 
treatment,  is  as  a  rule  well  and  promptly  corrected 
by  the  method  and  with  the  instruments  and  mate- 
rials most  conveniently  under  the  control  of  the  phy- 
sician responsible  for  the  case.     To  insure  success. 


Fig    25. — Case  I.,  Standing  with  Toes  Raised. 

however,  all  expectation  of  a  speedy  cure  should  be 
frankly  abandoned  at  the  outset,  and  preparation 
made  for  diligent  treatment  begun  soon  after  birth 


26  GROWTH  AND  DEFORMITY. 

and  continued  until  growth  is  well  advanced.  Bet- 
ter results  are  reached  by  patiently  relying  on  slow 
methods  and  natural  growth  than  by  resorting  to 
forcible  correction  repeated  whenever  the  deformity 
becomes  offensive  through  neglect.  There  is,  more- 
over, one  source  of  disappointment  which  should  be 
borne  in  mind,  and  that  is  the  idea  that  wearing  a 
brace  is  all  that  is  necessary.  A  brace  in  itself  is 
entirely  inefficient.  It  must  accomplish  a  constant 
definite  purpose,  which  it  can  be  made  to  do  only  by 
the  presence  and  alertness  of  an  intelligent  mind. 
The  most  faithful  and  anxious  parent  requires  fre- 
quent advice  and  supervision,  not  to  mention  the 
readjustments  and  alterations  of  apparatus  repeated- 
ly required  with  the  lapse  of  time  and  changes  in  the 
foot.  In  the  history  of  a  case  thus  managed  there 
will  be  intervals  of  considerable  length,  wdien  treat- 
ment may  be  suspended,  to  be  resumed  with  the  first 
sign  of  returning  deformity. 

FLAT-FOOT. 

The  human  foot,  for  many  reasons,  does  its  w^ork 
at  a  disadvantage.  The  corporal  weight  falls  on  tw^o, 
instead  of  four,  pedal  extremities,  as  in  some  other 
animals.  The  delicate  and  complicated  construction 
of  the  feet  and  the  small  floor  area  which  they  oc- 
cupy seem  out  of  proportion  to  their  duty  of  support- 


FLAT-FOOT.  27 

ing  the  towering  frame  above  them,  in  some  cases 
not  unhke  a  pyramid  on  its  apex.  The  carrying  of 
such  a  load  is  a  menace  to  these  overburdened  mem- 
bers, and  when  a  prolonged  effort  is  made  under  addi- 
tional weight,  as  by  a  native  carrier  in  strange  lands 
or  an  armed  soldier  on  a  forced  march,  the  endurance 
of  the  feet  excites  wonder.  With  the  common  ail- 
ments, such  as  corns,  bunions,  chilblains,  blisters, 
ingrowing  nails,  hammer  toes,  hallux  valgus,  Mor- 
ton's toe,  perforating  ulcers,  weak  ankle,  loss  of  the 
arch,  bursitis  and  osteitis,  the  foot  seems  destined  for 
disability  soon  after  the  journey  of  life  is  begun  and 
certainly  when  the  pilgrim  takes  on  the  fat  that 
goes  with  age  and  good  living.  It  \^'as  a  profane  re- 
mark of  Savarin,  the  great  gourmand,  that  among 
the  works  of  creation  the  design  of  the  human  foot 
was  a  conspicuous  failure.  It  is  sufTficiently  evident 
to  the  student  that  only  a  consummate  adaptation  of 
mechanics  has  enabled  this  discredited  member  to 
perform  its  superlative  functions.  He  should  there- 
fore undertake  its  reconstruction  only  after  a  good 
deal  of  hesitation.  The  treatment  of  disabled  and 
deformed  feet  is  indeed  beset  with  difficulty,  espe- 
cially if  undertaken  while  the  feet  are  in  use. 

One  of  the  common  ailments  is  impairment  or  loss 
of  the  arch,  deforming  the  foot,  but  less  serious  as  a 
deformity  than  as  a  painful  disability.  It  is  caused 
evidently  by  overuse  or  a  failure  to  appreciate  until 


28  GROWTH  AND  DEFORMITY. 

too  late  the  fact  that  machinery  of  this  kind  has  a 
hmit  of  endurance.  The  beginning  of  the  trouble  is 
insidious,  pain  resembling  that  of  rheumatism  shift- 
ing and  visiting  different  parts  of  the  foot  and  leg, 
and  accompanied  by  a  gradual  depression  of  the  arch, 
one  foot  preceding  the  other  on  the  downward  road. 
Periods  of  rest  are  followed  by  relief  from  pain,  but 
a  return  to  work  recalls  the  trouble.  After  a  few 
months  or  years  of  misery  the  feet  become  truly  fiat 
and  are  useful  and  painless  for  the  rest  of  life,  the 
related  and  coordinating  structures  having  gradually 
become  adapted  to  each  other  and  to  the  abnormal 
state  of  affairs.  Waiters,  chambermaids,  and  sales- 
men become  footsore  from  too  much  standing  and 
walking.  In  hospitals  it  is  a  common  affection 
among  nurses  who  have  not  before  been  much  on 
their  feet.  Rapid  growth  and  a  sudden  increase  in 
flesh  are  contributing  causes.  The  trouble  attacks 
bartenders  whose  hours  are  long  and  who  wear  thick 
soles  on  beer-soaked  floors,  and  it  is  said  to  be  com- 
mon in  boys  who  follow  the  plough  through  soft  soil 
in  heavy  boots. 

Direct  reinforcement  of  the  arch  by  an  upward 
curving  in-sole  is  naturally  the  first  suggestion  in  the 
way  of  treatment.  This  requires,  however,  very  skil- 
ful and  exact  adjustment,  since  a  great  and  active 
burden  must  be  supported  by  a  comparatively  slight 
substructure.     Many  cases  will  probably  be   better 


FLAT-FOOT.  29 

managed  indirectly,  as  by  a  change  to  some  occupa- 
tion requiring  less  work  from  the  feet.  As  this  is 
seldom  convenient,  relief  may  be  sought  by  taking 
advantage  of  heretofore  neglected  opportunities  to 
sit,  avoiding  unnecessary  walking  in  the  intervals  of 
work,  and  by  other  means  of  sparing  the  feet  which 
will  occur  to  the  mind  with  an  acquired  knowledge 
of  the  threatening  peril.  An  interesting  observation 
is  that  when  a  patient's  attention  is  called  to  the 
point  he  finds  it  easier  to  walk  up  a  moderately  in- 
clined path  than  down,  showing  that  a  desirable  po- 
sition is  that  of  flexion  of  the  foot  on  the  leg,  which 
may  be  promoted  by  lessening  or  removing  the  heel 
of  the  shoe.  In  other  ways  also  the  shoes  may  be 
improved.  The  sole  should  be  very  flexible  and  the 
ankles  left  free  from  constriction.  A  common 
method  of  strengthening  the  foot  by  tightly  lacing 
the  shoe  around  and  above  the  ankle  should  be 
omitted  as  a  vain  attempt  to  support  impending 
weight  by  inadequate  means. 

Shoes  made  especially  for  the  support  of  the  ankle 
are  useless  in  any  case,  and  especially  for  the  feet  of 
a  growing  child.  It  is  better  to  avoid  undue  fatigue 
and  to  look  for  natural  development  of  strength  and 
stability  b}^  moderate  exercise  of  the  feet  and  ankles 
unsupported.  Constriction  of  the  ankle  cannot  but 
impair  the  efficiency  of  the  muscles  of  the  leg,  which 
control  the  multiform  motions  of  the  foot  through  a 


30  GRO  WTH  AND  DEFORMITY. 

complex  system  of  tendons,  the  direction  of  which  is 
changed  by  turning  the  corner  of  the  ankle.  When 
restraints  are  removed  from  the  ankle,  and  especially 
when  shoes,  large  and  comfortable  in  other  respects, 
are  prescribed  for  flat-feet,  the  first  result  will  prob- 
ably be  an  increase  of  pain  in  locomotion,  which 
should  be  expected  after  a  sudden  change  of  this 
kind.  If  the  first  pain  and  inconvenience  are  en- 
dured they  cease  after  a  time  and  give  way  to  unex- 
pected comfort  and  surprising  ability  in  walking. 
The  patient  has  been  doing  the  wrong  thing  for  a 
long  time,  and  may  not  expect  a  sudden  and  painless 
return  to  the  path  of  rectitude.  He  may  be  exhorted 
in  the  words  of  Dr.  Fayette  Taylor,  who  was  wont 
to  say  that  one  could  not  go  up  hill  any  quicker  than 
he  went  down. 

Locomotion  in  a  painful  stage  is  facilitated  by 
transferring  weight  from  the  toe  to  the  heel.  This 
is  inferred  from  the  fact  that  comfort  comes  with 
removal  of  the  heel  from  the  shoe,  which  produces 
flexion  of  the  foot  on  the  leg,  an  attitude  in  which 
the  heel  is  thrust  down  toward,  and  the  toe  with- 
drawn upward  from,  the  ground.  It  is  well,  therefore, 
to  relieve  pain  by  leaning  a  little  backward  in  stand- 
ing and  walking,  which  moves  a  part  of  the  weight 
from  the  arch  to  the  heel.  It  may  not  be  possible  in 
many  cases  to  restore  the  lost  arch,  but  by  a  resort 
to  timely  rest  and  minor  devices,  commonplace  but 


ooqOi 


h'LAT-FOOT.  31 

effective,  comfort  and  ability  in  walking  may  be  as- 
sured. 

Minor  Afflictions  of  the  Feet. — Flat-foot  is  an  ail- 
ment for  which  there  is  really  no  good  excuse.  For 
the  results  of  joint  disease,  or  of  infantile  paralysis, 
the  patient  may  not  justly  be  held  accountable,  but 
with  prudence  and  intelligence  he  should  escape 
breaking  down  or  wear-  ^_^ 

ing  out  of  the  feet.     He  f      J 

should  also  be  held   to  r^  r^  /'^ 

account  for  other  com-  ^^ 

mon  ailments  such  as 
ingrowing  nails,  ham- 
mer toes,  hallux  valgus, 

and   corns  ^^^'  2&-— Alignment  of  Toes  Enforced 

by  Adhesive  Plaster  (1887). 

The  latter  afBiction 
may  be  eliminated  by  maceration  at  stated  intervals, 
in  a  tepid  saponic  solution,  and  removal  of  extra- 
neous epidermis  by  erasion.  If  this  domestic  pro- 
cedure is  repeated  only  when  pain  becomes  intol- 
erable, the  trouble  will  recur  interminably  through 
moderate  pressure  concentrated  on  underlying  bony 
processes. 

Hammer  toes  result  from  overcrowding  the  digits 
in  tight  shoes.  This  ill  may  be  relieved  by  amputa- 
tion of  the  rampant  toe  through  its  metatarsal  bone, 
an  operation  sometimes  practised,  it  is  said,  on  the 
second  digit  of  a  normal  foot  in  the  search  for  cos- 


32  GROWTH  AND  DEFORMITY. 

metic  effects.  Reduction  may  be  assisted  by  tiie 
application  of  a  narrow  piece  of  plaster,  as  in  Fig. 
26,  which  readily  corrects  overlapping  during  the 
time  of  growth. 

Ingrowing  nails  are  caused  by  thoughtless  rupture 
of  a  modiis  vivendi,  in  which  the  nail  preempts  a 
nidus,  and  the  callous  skin,  as  the  result  of  long  cus- 
tom, tolerates  the  lateral  edges  and  corners  of  the 
nail,  which  should  never  be  retrenched  except  by 
a  "bang"  stroke,  made  at  right  angles  with  the  axis 
of  the  phalanx.  Relief  in  the  worst  cases  surely  fol- 
lows the  necessarily  slow  restoration  of  the  modus 
vivendi  referred  to. 


CHAPTER    11. 

DEFORMITIES    AND    DISABILITIES    CAUSED   BY 
INFANTILE    PARALYSIS. 

When  the  eighteen  months  (\vhic]"i  are  said  to  be 
the  hmit  of  spontaneous  recovery  from  anterior  poHo- 
myehtis)  have  passed,  the  affected  muscles  are  found 
to  be  paralyzed  at  a  critical  time  in  the  child's  his- 
tory, when  the  development  of  the  joints  of  the 
lower  limbs  is  especially  rapid  under  the  incitement 
and  exertion  of  learning  to  walk.  Although  walking 
is  a  commonplace  act  and  receives  but  little  atten- 
tion, it  is  really  a  difficult  feat  learned  only  after  long 
and  laborious  practice,  in  which  the  will  commits  the 
machinery  of  locomotion  almost  entirely  to  reflex 
control. 

Comparative  Exemption  of  the  Upper  Limbs. — It  is 
in  the  lower  extremities  that  the  deformities  and  dis- 
abilities caused  by  this  form  of  paralysis  are  con- 
spicuous. They  rarely  attract  attention  in  the  upper 
limbs.  It  is  not  necessary  to  explain  this  fact  by 
the  supposition  that  the  affection  has  a  preference 
for  the  nervous  filaments  supplying  the  lower  extrem- 
ity. A  probable  explanation  is  offered  in  the  propo- 
sition that  sufficient  power  is  gained  in  the  upper 
3  33 


34  GRO  WTH  AND  DEFORMITY. 

extremity  and  not  in  the  lower,  because  in  the  former 
the  muscles  can  advance  from  small  to  great  efforts, 
gaining  power  gradually  by  increasing  use,  while  in 
the  latter,  where  there  is  failure  at  the  outset  to  con- 
trol the  weight  of  the  body,  the  fibres  miss  the  very 
beginning  of  development.  It  has  been  held  that 
assistance  given  gradually  to  muscles  thus  affected  is 
an  incitement  to  recovery  of  power.  Possibly  a  post- 
ponement of  the  erect  position  and  a  series  of  grad- 
uated exercises  enforced  through  the  period  of  early 
growth  might  measurably  restore  muscular  power 
and  avert  some  of  the  threatening  locomotor  dis- 
ability. 

PARALYSIS    OF   THE   ANTERIOR    MUSCLES 
OF   THE  THIGH. 

Occurring  as  an  epidemic  in  the  hot  season,  infan- 
tile paralysis  is  seldom  recognized  until  the  fever 
subsides  and  certain  groups  of  muscles  are  found  to 
have  lost  their  motor  innervation.  Affecting  the 
muscles  of  the  thigh,  it  entails  a  miserable  defect  in 
the  gait.  If  the  quadriceps  extensor  is  paralyzed  the 
foot  cannot  be  held  out  by  an  extension  of  the  knee 
when  the  patient  is  sitting,  and  in  walking  he  is  apt 
to  put  a  hand  on  the  lower  part  of  the  thigh  to  keep 
the  limb  from  flexing  and  causing  a  fall.  If  the 
treatment  of  such  a  case  is  neglected  or  postponed 
the  child  takes  a  crutch,  and  when  the  paralysis  is 


1 


INFANTILE  PARALYSIS.  35 

well  marked  the  whole  leg  is  consigned  to  disuse  and 
atrophy.  The  other  parts  of  the  limb  may  be  useful 
and  strong,  but  weakness  at  this  point,  like  the  re- 
moval of  the  keystone  from  an  arch,  demolishes  the 
whole  structure.  Disuse  leads  to  poor  circulation, 
the  limb  hangs  useless  against  the  crutch,  it  suffers 
from  cold,  and  in  various  ways  is  such  an  annoyance 
that  in  later  years  amputation  is  not  uncommonly 
a  welcome  resort.  Sometimes  the  attenuated  thigh 
and  leg  are  bound  together  to  form  a  stump  for  an 
artificial  limb. 

Treatment. — The  obvious  remedy  lies  in  mechani- 
cal reinforcement  coincident  with  growth  for  the 
purpose  of  lessening  present  disability  and  encourag- 
ing local  and  general  functional  development,  the 
recompense  being  future  unaided  locomotion  with 
the  broad  coaptated  surfaces  of  a  hyperextended 
joint.  The  points  of  pressure  and  counter-pressure 
required  in  such  a  case  are  indicated  by  the  arrows 
in  Figs.  27  and  28.  A  brace  applied  in  the  case  of  a 
child  weighed  one  pound  and  tw^o  ounces. 

Counter-pressure  is  made  at  the  lower  end  of  the 
brace  by  a  heel  cup  formed  by  webbing  riveted  to 
the  upright  and  to  the  border  of  the  tread,  in  the 
manner  shown  in  Fig.  40,  p.  48,  and  this  in  many 
cases  is  the  only  piece  of  webbing  in  the  whole  ap- 
paratus. ^  The  upright  may  occupy  the  inner  or  the 
outer  side  of  the  limb,  according  as  the  condition  of 


36 


GROWTH  AND  DEFORMITY. 


the  foot  requires  buckles  and  straps  for  opposing 
varus  or  valgus.  Aside  from  these  no  attachments 
are  needed,  the  splint  being  held  in  place  by  the  steel 


■^ 


Fig.  27. 


Fig.  28. 


Figs.  27, 


. — Points  of  Pressure  and  Counter-pressure  in  Paralysis  of  An- 
terior Muscles  of  the  Thigh  (1888). 


bands  which  half  encircle  the  limb;  their  tractable 
steel  should  be  so  curved  that  when  the  splint  is 
looked  through  endwise  the  lumen  formed  by  the 
steel  bands  should  not  much  exceed  the  antero-pos- 
terior  diameter  of  the  shaft  of  the  femur.  To  pre- 
vent rust  the  steel  may  be  wound  with  adhesive 
strips  and  some  convenient  renewable  fabric.  The 
stocking  will    intervene  between  the  skin  and  the 


INFANTILE   PARAL  YSTS. 


37 


lower  part  of  the  brace,  the  foot-piece  being  lined  as 
that  of  a  brace  for  club-foot.  The  chief  pressure 
falls  on  two  points  of  the  thigh,  an  upper  posterior 
and  a  lower  anterior  point;  but  pads  and  wadding, 
as  in  all  orthopaedic  apparatus,  are  better  avoided  as 
far  as  is  possible.  With  a  knee 
stiffened  in  this  way,  and  a  limb 
perhaps  otherwise  defective  in  in- 
nervation, walking  will  be  far  from 
graceful.  The  gait  will,  however, 
be  strong  and  effective,  and  the 
patient  will  be  gratified  by  his  abil- 
ity to  walk  a  longer  distance  and 
faster  than  before.  In  cases  of 
this  kind  every  additional  gain  in 
power  is  highly  valued.  When 
sitting  becomes  inconvenient  from 
increasing  length  of  limb  in  a  grow- 
ing patient  a  joint  may  be  intro- 
duced at  the  level  of  the  knee,  as 
in  Fig.  29,  with  automatic  fixation, 
alternating  with  voluntary  release, 
as  shown  in  Fig.  30.  A  brace  ap- 
plied in  the  case  of  a  very  heavy  patient  weighs  three 
pounds  and  eight  ounces.  It  gives  firmness  to  the 
gait  and  an  ability  to  fiex  the  knee  at  will.  Women 
thus  equipped  have  been  enabled  to  assume  the  de- 
votional duties  of  monastic  life. 


Fig.  29. — Brace  with 
Joint  at  the  Knee. 


38 


GROWTH  AND  DEFORMITY. 


Two  forms  of  "  release  "  are  seen  in  Figs.  31  and 
32,  the  "bucket"  and  the  "lever."     A  "fall  joint," 


Fig.  30. — Brace  Flexed. 


in  which  a  tube  or  hood  slides  down  the  upright  over 
the  joint  is  probably  more  easily  made,  but  in  order 


Fig.  31. — Details  of  "  Bucket  Release." 

to  allow  the  "fall"  to  be  raised  far  enough  to  clear 
the  joint  the  steel  band  must  occupy  a  level  where  it 


TALIPES   CALCANEUS.  39 

is  less  effective  in  keeping  the  knee  extended.  If 
both  of  the  lower  limbs  are  paralyzed,  the  patient 
creeps  or  relies  on  a   bearer  or  a  wheel-chair.     In 


QE 


Fig.  32. — Details  of  "  Lever  Release." 

such  a  case  the  application  of  a  brace  to  each  limb 
renders  locomotion  with  the  further  aid  of  a  pair  of 
crutches  entirely  practicable,  as  is  illustrated  in  Case 
IV.  (p.  57). 

TALIPES    CALCANEUS. 

Paralysis  of  the  fibres  which  move  the  tendo 
Achillis  causes  a  very  serious  locomotor  disability, 
but  one  easily  overcome  by  mechanical  means. 
When  the  action  of  the  heel  cord  is  eliminated  the 
patient  cannot  stand  on  tiptoe  and  his  weight  is 
necessarily  concentrated  on  the  heel.  The  result  is 
talipes  calcaneus,  which  implies  an  unimportant  de- 
formity, but  entails  a  serious  disability  in  which  the 
anterior  part  of  the  foot  is  entirely  useless.  The 
limb  in  locom.otion  is  reduced  to  the  condition  of  a 
peg  leg.     It  is  an  example  of  non-deforTning  club- 


40  GROWTH  AND  DEFORMITY. 

Joot.  The  term  club-foot  is  rather  loosely  applied  to 
all  the  varieties  of  talipes.  It  might  well  be  limited 
to  varus,  which  reduces  the  foot  to  the  appearance 
of  a  wooden  club.  The  other  varieties  (valgus,  equi- 
nus,  and  calcaneus)  are  attended  by  disability  rather 
than  deformity.  An  extreme  case  of  calcaneus, 
however,  presents  a  remarkable  deformity  with  its 
magnified  heel  and  insignificant  toe,  features  which 
are  quite  invisible  when  the  foot  is  dressed.  Ac- 
quired, or  paralytic,  calcaneus  is  readily  mistaken 
in  the  very  young  for  congenital  calcaneus,  which 
is  of  extremely  rare  occurrence.  An  example  pre- 
senting the  resistance  of  congenital  equino-varus 
would  be  well  worth  a  careful  description.  The  few 
cases  reported  have  yielded  to  little  treatment  or 
spontaneously  even  before  the  treatment  proposed 
could  be  applied.  In  an  ordinary  case  of  paralytic 
calcaneus  hopeless  elongation  of  the  heel  cord  soon 
appears.  Sanguine  confidence  in  reconstructive  sur- 
gery has  led  to  division  and  shortening  of  the  tendon 
by  sutures ;  but  its  elongation,  being  the  result  of 
sheer  inability  to  sustain  weight,  may  be  expected 
promptly  to  recur  after  such  an  operation.  The  con- 
dition in  talipes  calcaneus  resembles  that  caused  by 
amputation  at  the  tarso-metatarsal  junction,  which 
was  rudely  performed  by  the  American  aborigines 
when  they  wished  to  prevent  the  escape  of  a  captive 
slave. 


TA  L  IP  lis   CA  L  CA  NE  US. 


41 


"  The  Human  Wheel." — In  an  ingenious  analysis  of 
human  locomotion,  Dr.  Holmes  wrote:  "  Walking  is 
a  perpetual  falling  with  a  perpetual  recovery,  Man 
is  a  wheel  with  two  spokes,  his  legs,  and  two  frag- 
ments of  a  tire,  his  feet.  He  rolls  necessarily  on 
each  of  these  fragments  from  the  heel  to  the  toe.     If 


Fig.  33-  —  "  The  Human  Wheel"  (O.  W.  Holmes,  1S63). 


he  had  spokes  enough  he  would  go  round  and  round 
as  the  boys  do  when  they  '  make  a  wheel '  with  their 
four  limbs  for  its  spokes.  But  having  only  two 
available  for  ordinary  locomotion,  each  of  them  has 
to  be  taken  up  as  soon  as  it  is  used  and  carried  for- 
ward to  be  used  again,  and  so  alternately  with  the 
pair."  Observation  of  the  gait  of  a  patient  crip- 
pled by  this  form  of  paralysis  shows  that  some 
of   the   felloes  are  absent   from   the  human   wheel. 


42 


GROWTH  AND  DEFORMITY. 


The  result  is  irregular  locomotion   or  jolting  pro= 
gression. 

The  Strain  on  the  Tendo  Achillis. — An  obvious  func- 
tion of  this  tendon  is  to  support  the  body  on  tip- 


FiG.  34.  — Demonstration  of  Adverse  Lever  at  Ankle-joint.     First  Position, 
in  which  the  Strain  on  the  Tendo  Achillis  Equals  the  Weight  of  the  Body. 


TALIPES  CALCANEUS. 


43 


toe.  The  extravagant  size  of  the  muscles  found  in 
the  calf  is  accounted  for  by  the  fact  that  they  do 
their  very  exceptional  work  at  the  great  disadvan- 


FlG.    35. — Second    Position,   in  which  the  Strain  on  Tendon  is   Trebled 

(1S90). 


44  GROWTH  AND  DEFORMITY. 

tage  of  a  remarkable  adverse  lever  at  the  ankle-joint. 
The  strain  falling  on  the  heel  cord  may  be  appre- 
ciated experimentally  by  a  device  which  shows  that 
treble  the  weight  of  the  body  represents  the  tension 
on  the  tendo  Achillis.  In  Figs.  34  and  35  the  weight 
of  the  body  is  represented  by  a  four-pound  bag  of 
shot.  The  machine  being  held  on  a  table,  the  bal- 
ance is  seen  to  vary  in  its  registry  when  the  joint 
representing  the  ankle  is  moved  to  different  points 
between  the  heel  and  toe.  When  the  joint  is  near 
the  toe  a  small  fraction  of  a  pound  is  registered,  but 
when  it  is  near  the  heel  the  index  points  to  twenty 
pounds  or  twenty-four  pounds.     In  Fig.  34  the  ankle 


Fig.    36. — Relation  of    the    Joint  to    the   Tendo    Achillis    and    the    Toe 

(Marshall,  1863). 

is  midway  and  the  balance  reads  four  pounds,  show- 
ing that  if  the  ankle  were  at  this  point,  the  strain  on 
the  tendon  would  be  that  of  the  weight  of  the  body. 
In  Fig.  35  the  joint  is  three  inches  from  the  heel  and 
nine  inches  from  the  toe,  which  approximates   its 


TALIPES   CALCANEUS. 


45 


relative  position  in  the  foot  as  shown  in  Fig.  36.  In 
this  position  the  scale  reads  twelve  pounds,  or  three 
times  the  weight  of  the  shot,  demonstrating  that  if 
a  boy  weighs  one  hundred 
pounds,  the  tiptoe  strain  on 
his  tendo  Achillis  is  three 
hundred  pounds.  Practical- 
ly the  strain  is  often  greater, 
being  the  sum  of  weight 
plus  momentum.  The  lever 
present  is  of  the  second 
order,  in  which  the  weight 
is  between  the  power  and 
fulcrum  as  seen  in  Fig.  y], 
where  the  forces  in  equilib- 
rium about  the  fulcrum,  C, 

are  the  upward  tension  of  the    FrG.37.-Mathematical  Demon- 

stration  (1890). 

heel  cord,  T,  and  the  down- 
ward pressure  of  the  tibia,  D  B,  at  B,  represented  by 
R.  The  moments  being  equal,  T  X  AC  =  R  X  B  C. 
As  R  is  the  resultant  of  the  tension  of  the  heel  cord 
and  the  resistance  of  the  ground  at  C,  equal  to  the 
weight  of  the  body,  represented  by  W,  R  =  T  +  W. 
Therefore  T  X  AC  =  (T  +  W)  BC,  or  T  X  AC  =  T 
XBC+WxBC,  or  TxAC-TxBC  =  Wx 
BC.  But  AC  -  BC  -  AB.  Therefore  T  x  AB  = 
W  X  BC 


W  X  BC,  or  T  = 


A  B 


If  now  the  weight  of 


46 


GROWTH  AND  DEFORMITY. 


the  body  is  one  hundred  and  fifty  pounds,  and  the 
distance  from  the  ankle  to  the  toe  six  inches  and  that 
from  the  ankle  to  the  heel  three  inches,  the  tension 

is  — — "- —  or   — ,  or  three  hundred  pounds.     Dr.  Wirt 

reached  practically  the  same  conclusion  by  the  use 
of  cosines. 

Very  little  deformity  is  produced  by  either  an 
elongated  or  a  shortened  heel  cord.  But  in  their 
effect  on  locomotor  ability  they  are  widely  different. 
A  short  tendon,  unless  it  is  ex- 
cessively short,  causes  no  lame- 
ness. It  does  not  prevent  a  per- 
fect gait  and  prolonged  exertion 
in  dancing  or  on  a  march,  and 
it  may  be  useful  in  maintaining 
the  equine  foot  when  factitious 
length  is  desired  for  a  shortened 
limb.  Dr.  Hibbs  has  made  an 
important  study  of  a  series  of 
cases  in  which  subcutaneous  divi- 
sion of  the  tendon  had  seriously 
affected  its  relation  to  the  mus- 
cles of  the  calf.  Civilized  man 
assumes  few  positions  which  are 
interfered  with  by  a  moderately  short  tendo  Achillis, 
while  a  lengthened  tendon  urgently  demands  com- 
pensation.    This  may  conveniently  be  found  in  the 


Fig.  38. — Brace  used 
in  Case  II.,  Talipes 
Calcaneus  (i8go). 


TALIPES   CAL  CANE  US. 


47 


application  of  a  brace  such  as  is  shown  in  Figs.  38, 
39,  and  40. 

Treatment. — The  steel  band  at  the  upper  part  of 
the  brace  gives  attachment  to  buckles  which  receive 
a  strap  against  which  the 
patient  kneels  when 
throwing  his  weight  on 
the  brace.  When  rising 
on  his  toe  he  has  a  com- 
posite sensation  of  stand- 
ing and  kneeling.  The 
pressure  of  kneeling  is 
felt  near  the  tubercle  of 
the  tibia,  and  to  this  point 
is  transferred  the  callous 
condition  of  the  ball  of 
the  foot,  and  here  fre- 
quently is  found  an 
adventitious  bursa  of  con- 
siderable size.  A  verti- 
cal upright  affords  relief, 
but  a  better  effect  may 
be  obtained  by  inclining 


Fig.  39. — A  Later  Brace  (1898). 


it  backward  experimentally  until  the  inclination  is 
found  at  which  walking  is  most  easily  done.  Such  a 
brace  cannot  of  course  furnish  the  active  power  which 
the  muscles  of  the  calf  exhibit  in  running  and  jump- 
ing, but  it  gives  sustaining  power  to  the  anterior  part 


48 


GRO  WTH  AND  DEFORMITY. 


of  the  foot  and  restores  normal  walking,  in  which  the 
patient  rolls  from  the  heel  to  the  toe.  The  upright 
may  readily  be  inclined  backward  by  bending  the 

foot-piece  downward  when  it 
is  a  simple  tread  without  a 
riser,  as  shown  in  Figs.  39 
and  40.  These  braces  weigh 
two  pounds  three  ounces  and 
one  pound  three  ounces. 
They  are  worn  by  an  adult 
and  a  child  respectively.  If, 
however,  calcaneus  is  compli- 
cated with  lateral  deviation, 
the  riser  necessary  for  the  cor- 
rection of  varus  or  valgus  pre- 
vents bending  of  the  tread, 
and  the  upright  of  such  a 
brace  as  is  seen  in  Fig.  41 
may  then  be  bent  by  experi- 
mental blows  with  a  heavy  hammer  until  the  proper 
angle  is  found,  and  in  subsequent  braces  a  straight  up- 
right may  be  set  at  the  determined  angle.  A  joint 
at  the  ankle  is  unnecessary.  It  adds  to  the  cost, 
is  useless,  and  soon  wears  out  under  the  rapidly  re- 
peated blows  which  attend  locomotion.  The  brace  is 
worn  over  a  stocking  for  comfort  and  under  another 
stocking  for  concealment.  Worn  during  adoles- 
cence, such  an  apparatus  abolishes  present  lameness 


•Fig.  40. — A  More  Recent 
Brace  in  which  the  Up- 
right and  Tread  are  of 
One  Piece  (1902) . 


TALIPES   CALCANEUS.  49 

and  lessens  cavus  in  after-life.  It  secures  remark- 
able excellence  in  walking,  whatever  may  be  the 
hypertrophy  of  the  heel  and  the  atrophy  of  the  ante- 
rior part  of  the  foot. 

Case  II. — Right  Talipes  Calcaneus. — In  1879,  a 
girl  eleven  years  old  had  been  lame  for  several  years 
following  an  attack  of  "  worm  fever."  She  had  char- 
acteristic inability  to  stand  on  tiptoe  with  the  affected 
foot,  an  enlarged  heel,  and  a  wasted  limb.  The 
brace  seen  in  Fig.  ^^,  weighing  one  pound  and  eight 
ounces,  restored  ability  to  use  the  anterior  part  of  the 


Fig.  41. — Case  II.,  Standing  Tiptoe  with  Help  of  Brace  (1885). 

foot,  and  corrected  asymmetry  of  gait.  An  instan- 
taneous photograph,  taken  in  1885,  is  copied  in  Fig. 
41,  when  the  affected  leg,  from  atrophy  of  the  mus- 
cles of  the  calf,  was  nearly  three  inches  smaller  than 


50  GROWTH  AND  DEFORMITY. 

the  well  one.  In  1890  she  wrote  that  the  brace  main- 
tained a  normal  gait  and  was  always  in  use  out  of 
doors,  and  when  housework  was  to  be  done. 


PARALYTIC  TALIPES  VARUS  AND  VALGUS. 

Infantile  paral3^sis  is  the  cause  of  several  other 
forms  of  disability  in  locomotion.  If  the  muscles  on 
one  side  of  the  leg  are  paralyzed,  the  foot  turns  in  the 
other  direction.  As  muscular  failure  is  the  cause  of 
acquired  talipes,  it  is  necessary  to  understand  the  part 
which  the  muscles  take  in  locomotion. 

Mechanics  of  Locomotion. — The  common  idea  that 
the  muscles  push  the  body  along  is  not  in  accordance 
with  the  facts.  They  may  do  so  when  a  man  climbs  a 
tree  or  ascends  a  steep  hill,  but  ordinary  walking  is  a 
complex  and  yet  a  simple  procedure  in  which  the 
muscles  do  not  play  a  very  heroic  part.  First  the  body 
leans  in  the  selected  direction,  then  the  feet  swing 
forward  one  after  the  other,  and  the  act  of  walking 
is  completed  by  muscular  contraction,  which  simply 
holds  the  feet  steady  under  the  weight  of  the  advanc- 
ing body,  which  falls  first  on  one  foot  and  then  on 
the  other,  in  accordance  with  Dr.  Holmes'  view  that 
walking  is  a  perpetual  falling  with  a  perpetual  recov- 
ery. Illustrations  are  found  in  the  leaning  figure  of 
a  little  child  just  beginning  to  walk  and  in  that  of  a 
man  in  alcoholic  titubation.     The  spectators  look  for 


PARALYTIC    VARUS.  51 

a  fall  which  seldom  comes.  It  may  be  said  that  the 
faster  one  walks  the  more  imminent  is  the  perpetual 
falling,  and  the  more  instantaneous  the  perpetual  re- 
covery. Success  in  a  race  evidently  depends  largely 
on  one's  superior  ability  to  get  the  feet  under  the 
body  as  it  falls  forward.  It  may  not  be  easy  to  give 
up  the  idea  that  the  feet  and  legs  push  the  body  for- 
ward. The  foot  certainly  spurns  the  ground  in  the 
wake  of  the  runner  in  a  very  vigorous  manner^  but 
the  recoil  of  this  stroke  simply  propels  the  foot  for- 
ward as  it  hastens  to  receive  the  weight  of  the  falling 
body. 

Talipes  Varus. — With  this  understanding  of  the 
mechanics  of  locomotion,  it  is  interesting  to  note  that 
when  the  weight  of  the  body  falls  on  the  limb  in  the 
act  of  walking,  the  muscles  on  all  sides  responding 
to  a  call  for  concerted  action  instantly  contract  by  a 
common  reflex  impulse  to  maintain  the  stability  of 
the  foot.  At  this  crisis,  if  those  on  the  outer  side, 
for  instance,  are  paralyzed  and  unable  to  obey  the 
call,  those  on  the  inner  side,  suddenly  contracting 
without  opposition,  throw  the  foot  into  talipes  varus, 
which  the  weight  of  the  body  and  the  blows  of  loco- 
motion soon  aggravate  and  which  growth  presently 
makes  offensive  and  irreclaimable. 

Contrary  to  public  opinion,  cases  of  club-foot  are 
more  commonly  of  paralytic  than  of  congenital  origin. 
A  foot  deformed  at  birth  is  recognized  at  once.     It 


52  GROWTH  AND  DEFORMITY. 

is  apt  to  receive  prompt  attention  in  an  early,  plas- 
tic, and  rapidly  growing  stage,  when  it  is  easily  made 
to  grow  straight.  But  incipient  paralytic  club-foot  is 
insidious.  When  the  trouble  is  noticed  there  is  sim- 
ply a  defect  in  gait  which  it  is  hoped  will  be  "  out- 
grown," Being  painless,  and  not  severely  disabling, 
it  is  apt  to  be  neglected  until  the  shortened  fibres 
and  misshapen  bones  seriously  oppose  restoration. 
If  such  a  foot  be  taken  in  hand  at  once  the  bones  will 
be  found  in  normal  shape  and  the  fibrous  structures 
wall  be  relaxed.  In  this  stage  reduction  is  easy,  the 
appearance  being  that  of  the  foot  seen  in  Fig.  lo 
(see  p.  lo). 

Treatment  may  be  the  same  as  that  described  in 
the  later  stage  of  congenital  varus.  The  foot  should 
be  held  by  a  brace  in  its  normal  shape  until  growth 
and  bodily  weight  confirm  restoration  (pp.  9-14). 
The  treatment  of  congenital  varus  is  generally  re- 
warded by  the  full  measure  of  success,  but  the  result 
of  treatment  in  a  case  of  paralytic  varus  will  prob- 
ably be  marred  by  the  presence  of  paralysis  in  other 
parts  of  the  limb.  Not  uncommonly  the  brace  must 
extend  abo\'e  the  knee  to  reinforce  the  extensors  of 
the  leg  while  the  varus  is  under  correction. 

Talipes  Valgus. — ^If  the  muscles  on  the  inner  side 
of  the  leg  are  paralyzed  their  opponents  will  produce 
valgus,  a  variety  of  talipes  less  deforming  and  dis- 
abling than  varus,  and  usually  overshadowed  b}"  the 


TALIPES    VALCWS 


53 


concurrence  of  calcaneus,  which  is  more  serious  in 
its  effect  on  locomotion  than  valgus  but  fortunately 
more  easily  managed.  Deformities  of  the  foot  simu- 
lating the  effects  of  infantile  paralysis  have  their 
rise  in  the  disintegration 
which  undermines  the 
bones  in  locomotor  at- 
axia. An  instance  of  tab- 
etic valgus  is  shown  in 
Fig.  42.  The  abnormal 
muscular  action  of  Fried- 
reich's disease  produces 
similar  results.  In  these 
cases  the  primary  affec- 
tion is  so  disabling,  local- 
ly and  generally,  that  me- 
chanical relief  is  seldom 
practicable.  In  favor- 
able conditions,  however, 
purely  prosthetic  appara- 
tus is  useful  in  giving 
stability  to  the  ankle,  lat- 
eral support  in  Charcot's  knee,  or  stiffness  to  the 
knee,  by  the  action  of  an  automatic  joint,  prolonging 
the  period  in  which  walking  is  possible  with  the 
aid  of  crutches. 


Fig.  42. — Tabetic  Talipes  Valgus. 
Man,  Thirty-five  Years  Old, 
New  York  Hospital  (i8g8). 


54  GROWTH  AND  DEFORMITY. 

DETAILS   OF   TREATMENT   OF   PARALYTIC 
DISABILITIES. 

In  persistent  varus,  as  in  all  cases  which  require 
pressure  on  prominences  near  a  joint,  metallic  con- 
tact should  give  way  to  webbing  under  convenient  ad- 
justment by  buckles  so  distributed  as  to  draw  the 
deformed  part  into  a  recess  formed  by  bending  the 
frame  of  the  brace.  When  pressure  is  to  be  made 
on  the  shaft  of  a  bone,  however,  as  in  the  reinforce- 
ment of  the  extensor  femoris,  illustrated  in  Figs.  27 
and  28  (on  p.  36),  the  bone  will  be  found  partially 
cushioned  by  subcutaneous  tissues,  and  care  should 
be  taken  to  bend  and  twist  the  steel  till  its  whole  sur- 
face of  contact  is  evenly  applied  to  the  bony  surface 
receiving  the  pressure.  Padding  and  protecting  wads 
do  imperfectly  and  uncomfortably  what  may  be  bet- 
ter done  by  conforming  the  steel  frame  of  the  brace. 
As  apparatus  of  this  kind  furnishes  support  which 
the  bones  fail  to  give,  it  may  be  likened  to  an  outside 
skeleton,  like  that  of  a  lobster  or  of  a  crab,  but  ap- 
plied with  difficulty  to  the  sensitive  skin.  In  the  pres- 
ence of  even  this  hindrance  a  supporting  apparatus 
may  be  so  well  designed  and  fitted  as  to  preclude 
a  demand  for  cushions  and  padding,  the  absence 
of  which  will  simplify  the  application  and  make 
prominent  its  essential  mechanical  features.  In  a  rea- 
sonable time  the  skin  becomes  callous  and  ceases  to 


PARALYTIC  DISABILITIES.  55 

resent  pressure,  and  tlie  patient  readily  accepts  incon- 
venience if  locomotion  is  made  easy  and  effective. 
Occasional  l^reaks  in  the  steel  show  the  points  that 
require  strengthening  and  prove  that  the  brace  is 
doing  under  strain  what  was  intended.  In  some  cases 
it  is  a  good  plan  to  have  braces  made  in  duplicate, 
so  that  repairs  may  be  made  without  inconvenience. 
To  adjust  such  an  appliance  and  to  keep  it  progres- 
sively effective  during  growth  and  the  development  of 
tardy  muscular  power  require  considerable  time  and 
attention,  but  otherwise  the  expense  is  not  great  and 
should  not  forbid  this  relief  to  those  who  in  strait- 
ened circumstances  stand  more  in  need  of  it  than 
others. 

The  Importance  of  Early  Treatment  may  be  em- 
phasized by  a  consideration  of  the  unhappy  condition 
©f  quite  a  number  of  adults  who  suffer  from  various 
degrees  of  lameness,  some  of  them  being  so  disquali- 
fied for  locomotion  as  to  require  bearers  and  wheel- 
chairs. Treatment  of  a  case  of  this  kind  may  fail 
because  of  the  difficulty  which  an  adult  has  in  ac- 
commodating himself  to  new  restraints  and  sup- 
ports, things  which  a  child  does  not  object  to  and 
soon  enjoys  if  they  extend  his  radius  of  play  and  mis- 
chief. Some  of  this  hesitation  is  reasonable  and  ex- 
cusable because  of  the  time  taken  for  defective  groups 
of  muscles  to  develop  the  power  called  for  and  neces- 
sary before  the  appliance  can  give  increase  of  ability. 


S6  GROWTH  AND  DEFORMITY. 

Neglected  muscles  respond  rapidly  to  such  demands 
in  childhood.  They  may  not  be  expected  to  answer 
so  promptly  later  in  life  and  the  adult  will  not  so 
readily  endure  the  uncomfortable  and  unaccustomed 
fatigue  which  is  the  preliminary  and  accompaniment 
of  muscular  development. 

Case  III . — Disability  following  Infantile  Paraly- 
sis.— A  man,  35  years  old,  had  spent  most  of  his 
years  on  crutches.  His  disability  had  received  a 
great  variety  of  treatment  and  mechanical  attention 
at  home  and  abroad.  The  anterior  part  of  the  left 
foot  was  useless  from  defective  leg  muscles,  and  the 
right  limb  was  disabled  by  paralysis  of  the  anterior 
muscles  of  the  thigh.  With  these  two  points  rein- 
forced, he  would  have  been  in  a  position  to  dispense 
with  crutches,  still  walking,  of  course,  with  consider- 
able lameness.  When  a  trial  was  made,  beginning 
with  a  brace  for  the  affected  foot,  it  was  seen  that  it 
called  for  the  use  and  development  of  other  groups 
of  muscles  also,  in  the  extremity  and  even  in  the 
trunk.  This  would  have  been  brought  about  easily 
in  the  case  of  a  child,  but  it  was  too  much  for  the 
matured  muscular  system  of  an  adult,  and  withal 
called  for  such  a  change  in  the  man's  habits  and  set- 
tled beliefs  as  to  his  physical  condition  that  the  treat- 
ment, hesitatingly  begun,  was  rather  eagerly  aban- 
doned. 

On  the  other  hand,  assistance  of  this  kind  offered 


PARALYTIC  DISABILITIES.  57 

in  childhood  has  in  many  instances  favored  the  de- 
velopment throughout  the  time  of  growth  of  impor- 
tant muscular  groups  and  has  thus  secured  comfort 
and  ability  and  nearly  symmetrical  locomotion  in 
after-life.  One  such  patient,  a  woman,  says  that  mis- 
taken friends  advise  her  to  lay  the  heavy  contrivance 
aside,  but  the  whole  muscular  system  having  made 
its  growth  in  accord  with  the  support  which  a  part 
has  received  from  the  brace,  she  finds  it  too  useful  to 
be  discarded.  Another  always  wears  the  brace  when 
in  "  company "  in  order  to  appear  well,  the  absent 
muscular  power  having  its  place  taken  by  the  artifi- 
cial support,  and  the  developed  accessory  muscles 
helping  to  complete  the  symmetry  of  locomotion. 

Case  IV. — Disability  folloiving  Infantile  Pai^aly- 
sis. — A  noteworthy  instance  is  that  of  an  apparently 
healthy  boy  who  at  the  age  of  14,  was  unable  to  stand 
on  account  of  a  belated  attack  of  infantile  paralysis. 
Apparatus  was  applied  for  automatic  fixation  of  each 
knee  in  the  extended  position,  allowing  him  to  walk 
with  crutches,  and  voluntary  release  of  fixation  when 
he  desired  to  flex  the  limbs  in  sitting.  Thus  assisted 
and  incited,  the  unused  muscles  in  various  parts  of 
the  body  developed  with  exercise  and  the  comple- 
tion of  growth.  In  this  way  he  was  enabled  as  a  boy 
and  as  a  young  man  to  do  more  than  the  average 
amount  of  work  without  any  personal  aid  whatever, 
and  he  now  enjoys  an  active  legal  practice,  not  neg- 


58  GROWTH  AND  DEFORMITY. 

lecting  vacation  sports  and  pastimes  ashore  and 
afloat,  although  his  attenuated  lower  limbs  are  in 
marked  contrast  with  an  heroic  torso  and  upper 
limbs.  That  he  is  not  limited  to  locomotion  in  a 
wheel-chair  is  owing  to  the  fact  that  the  failing  mus- 
cles and  joints  received  mechanical  encouragement 
at  the  time  of  growth,  an  advantage  which  might  well 
be  accorded  to  every  case  of  this  affection. 

Recognition  of  Mechanical  Surgery. — It  is  evident 
that  an  instrument  applied  for  the  relief  of  disability 
following  paralysis  supplies  a  defect  in  the  anatomy. 
To  that  extent  it  is  a  prosthetic  apparatus.  It  need 
not,  however,  on  that  account  be  omitted  from  the 
armamentarium  of  the  surgeon.  The  application  of 
braces  of  all  kinds  is  passing  into  professional  hands 
from  those  of  the  instrument  maker.  In  the  dark 
ages,  when  surgical  work  was  in  the  province  of  the 
barber,  the  medical  men  of  the  day  probably  waived 
professional  convention  when  they  ventured  to  take 
up  the  lancet  and  bistoury. 

In  1862  Dr.  Stephen  Smith  wrote:  "It  must  be 
evident  to  every  one  that  mechanical  surgery  is  a 
branch,  and  a  most  desirable  one,  of  surgical  science 
and  art.  It  is  not  simply  a  branch  of  mechanics  to 
which  any  ingenious  artisan  can  successfully  turn  his 
attention ;  it  requires  also  an  accurate  knowledge  of 
anatomy,  of  physiology  and  of  surgery.  Rationally, 
the  mechanical  surgeon  must  be  a  thoroughly  edu- 


MECHANICAL    SURGERY.  59 

cated  physician  as  \\ell  as  an  inventive  genius.  Med- 
ical men  of  real  merit  have  recently  entered  this  field 
of  service  and  already  the  ripe  fruits  of  skilled  labor 
begin  to  appear."  The  far-seeing  wisdom  of  this  ob- 
servation is  attested  by  the  fact  that  within  six  years 
after  these  words  had  been  penned,  The  New  York 
Hospital  for  the  Ruptured  and  Crippled  and  The 
New  York  Orthopaedic  Dispensary  and  Hospital  had 
been  established  or  incorporated.  The  work  done  by 
these  institutions  prepared  the  way  for  the  present 
wide  recognition  by  charitable,  educational,  and  gov- 
ernmental interests  of  the  value  of  this  field  of  special 
study  and  effort. 

An  Orthopaedic  Laboratory. — The  following  state- 
ment of  instruments  and  materials  is  considerably 
reduced  and  modified  from  a  schedule  presented  by 
Dr.  Schapps,  when  he  described  the  equipment  of  a 
new  orthopaedic  dispensary.  These  appliances  are 
necessary  for  the  application  and  modification  of 
braces  made  to  order  from  soft  steel  by  an  instru- 
ment maker:  Work-bench,  vise,  screwdrivers,  rivet- 
ing hammer,  files,  flat  and  cutting  pliers,  monkey- 
wrenches,  Stillson's  wrench,  hack-saw,  cold  chisel, 
punches,  centre-punch,  copper  rivets  No.  13,  various 
lengths,  burs,  steel  wire  for  rivets,  rivet  set,  shoe 
knife,  scissors,  snips,  oil  stone,  can  of  oil,  machine 
screws,  broaches,  taps,  hand  vise,  eyelets  and  set, 
leather  punch,  foot  drill  or  lathe,  twist  drills,  machine 


6o  GROWTH  AND  DEFORMITY. 

for  general  sewing,  truss  leather,  felt,  buckles  for  web- 
bing and  leather,  cotton  surgical  webbing,  pans  for 
holding  rivets,  burs,  screws,  buckles,  etc. 

Apparatus  not  only  Prosthetic  but  also  Preventive 
and  Therapeutic. — ^A  brace  applied  in  a  case  of  infan- 
tile paralysis  has  especial  value  for  a  growing  patient 
because  its  effect  is  not  only  to  improve  the  present 
gait  but  also  to  induce  related  structures,  which  would 
otherwise  have  remained  dormant,  to  develop  by  exer- 
cise and  the  increasing  demands  of  coordination, 
until  they  play  an  important  part  in  the  attainment 
of  ability  and  grace.  An  adult  would  of  course  gain 
some  advantage,  but  far  from  the  full  benefit  which 
would  have  been  his  if  all  the  machinery  of  locomo- 
tion had  made  its  growth  under  the  influence  of 
timely  reinforcement  of  the  deficient  part. 

These  disabilities  require  early  and  very  prolonged 
attention  in  practice.  When  the  lameness  of  a  child 
is  recognized  as  the  result  of  infantile  paralysis  and 
acknowledged  to  be  incurable  the  limp  is  considered 
unfortunate,  of  course ;  but  if  the  condition  does  not 
include  absolute  disability,  it  as  a  rule  receives  little 
serious  attention  in  the  way  of  treatment.  Presently, 
however,  as  the  child  grows,  the  misfortune  becomes 
more  conspicuous.  The  machinery  of  locomotion 
falters  more  and  more  under  increasing  w-eight,  and 
when  contractions  and  deformities  are  added  to 
atrophy  and  muscular  insufiiciency,  acute  attention 


MECHANICAL    SURGERY.  6i 

is  aroused  and  braces  are  sought  and  operations  are 
performed.  A  better  plan  is  to  assume  that  me- 
chanical assistance  is  required  at  the  outset — and 
will  be  necessary  throughout  the  time  of  growth, 
and  afterward.  It  is  true  that  treatment  thus  pro- 
longed and  troublesome  can  only  palliate  and  not 
cure.  It  implies  also  exacting  attention  to  me- 
chanical details,  frequent  supervision,  and  many  al- 
terations and  adjustments  of  apparatus  in  response 
to  the  demands  of  growth  and  increasing  ability. 
Improvement  in  walking  is  seen  at  once,  but  more 
important  benefits  will  accrue  later  when  it  is  found 
that  continued  use  of  the  brace  promotes  symmetry 
of  the  affected  limbs  and  flexibility  of  the  joints,  con- 
serves muscular  power  which  would  otherwise  have 
been  lost  through  disuse,  develops  extensive  related 
groups  of  muscles  in  other  parts  of  the  body,  and  pre- 
serves or  restores  various  allied  functions  and  abili- 
ties which  materially  add  to  the  efficiency  and  com- 
fort of  the  adult.  When  practicable,  this  end  is 
certainly  preferable  to  the  result  of  systematic  neg- 
lect, or  a  spasmodic  resort  to  treatment  whenever  its 
repetition  seems  to  be  especially  necessary.  In  this 
direction  a  change  is  noted  in  the  views  of  physicians 
and  of  the  public. 

Orthopaedic  Surgery  as  a  Specialty. — While  the 
troubles  seen  in  the  wake  of  infantile  paralysis  may 
be  greatly  relieved,  the  nerve  lesion  persists,  and  from 


62  GROWTH  AND  DEFORMITY. 

the  nature  of  the  case  there  will  almost  certainly  be 
a  lasting  residuum  of  disability.  The  result  of  treat- 
ment falls  short  of  perfection,  but  the  same  may  be 
said  as  a  rule  oi  the  treatment  of  spinal  deformity 
and  joint  disease,  and  in  fact  of  nearly  all  of  the  af- 
fections included  in  orthopaedic  practice.  This  has 
been  advanced  as  one  of  the  reasons  among  others 
for  the  existence  of  such  a  specialty  as  orthopaedic 
surgery.  The  limitations  of  achievement  are  so  con- 
spicuous and  so  sure  to  bring  discredit  upon  medical 
authority  that  it  seems  to  have  been  agreed  that  the 
inevitable  may  well  be  transferred  to  a  specialist,  who 
collects  what  is  known  on  a  certain  subject,  so  that 
when  the  end  of  treatment  is  reached  it  may  be  said 
that  the  patient  has  received  all  that  the  science  of 
medicine  in  its  present  state  allows.  The  orthopaedic 
surgeon  may  be  the  depository  of  exceptional  knowl- 
edge, but  his  work  includes  not  many  opportunities 
to  obtain  brilliant  results  or  to  achieve  operative  suc- 
cess, which  is  so  greatly  and  so  justly  admired  in  the 
public  mind.  He  throws  a  deformed  foot  into  a  new 
attitude  in  which  increasing  activity  and  growth  pro- 
mote and  insure  symmetry.  He  gives  to  a  tubercu- 
lous joint  a  new  environment  favorable  to  natural 
repair  and  recovery  with  an  unexpected  restoration 
of  locomotor  ability.  He  provides  a  reenforcement 
for  a  paralyzed  limb  which  meets  the  immediate  ne- 
cessity of  the  case  and  secures  future  activity  and 


MECHANICAL    SURGERY.  63 

comfort.  A  studious  application  of  the  methods  of 
precision  on  which  he  rehes  cultivates  his  aptitude 
for  mechanics  and  fosters  his  respect  for  whatever  is 
physically  demonstrable.  If  he  adds  to  natural  in- 
genuity an  inherited  or  acquired  preference  for  slow 
and  sure,  rather  than  rapid  and  indeterminate  meth- 
ods, he  is  in  a  position  to  witness  and  reverently  to 
assist  constantly  recurring  natural  miracles  in  repair 
and  recovery,  not  forgetting  the  friendship  of  his 
little  patients,  their  pretty  bashfulness,  ready  confi- 
dence, irrepressible  cheerfulness  and  graceful  accept- 
ance of  what  is,  alas,  inevitable.  The  combination 
in  their  young  lives  of  childish  and  heroic  qualities 
suggests  a  fantasy  in  which  birds  and  wild  flowers 
act  a  tragedy  and  improve  the  precepts  of  stoic  phi- 
losophy. 


CHAPTER    III. 

TUBERCULOUS   JOINT   DISEASE. 

An  Affection  of  Childhood. — Its  Causes. — Tubercu- 
losis of  the  joints  is  especially  a  menace  to  childhood ; 
and  yet  in  this  period,  when  the  vital  processes  are  at 
their  best  and  growth  and  development  are  active,  it 
would  seem  that  natural  resistance  to  general  diseases 
should  be  alert  and  give  protection  from  dangers  of 
this  kind.  In  early  youth  the  circulation  is  rapid  and 
full.  Children  are  not  easily  deprived  of  their  share 
of  respiratory  activity.  They  are  not  given  to  intro- 
spection and  melancholy  which  has  been  thought  to 
favor  the  approach  of  general  or  constitutional  dis- 
ease. Their  habits  are  far  from  sedentary.  Their 
minds  are  free  from  worry  and  their  bodies  from 
overwork  and  long  hours  without  rest  and  recreation. 
By  this  process  of  exclusion,  their  danger  may  per- 
haps be  referred  to  some  mismanagement  of  alimen- 
tation. Some  unfortunates  are,  from  sad  necessity, 
denied  sufificient  food.  Others  perhaps  suffer  because 
prudent  economy  finds  easy  expression  in  a  scanty 
allowance  to  the  younger  members  of  the  family,  re- 
enforced  by  a  common  and  not  altogether  unreason- 

6-1 


rUBER CUL  O US  JOINT  I)/ SEA  SE.  65 

able  idea  that  it  is  bad  for  a  child  to  eat  too  much. 
Overeating  may  of  course  induce  acute  disorders  of 
brief  duration,  but,  on  the  other  hand,  prudence  of 
this  kind  may  easily  lead  to  the  more  serious  mistake 
of  opening  the  door  for  chronic  affections  by  with- 
holding sufficient  nourishment.  Certain  young  pa- 
rents who  have  no  reason  for  economy  seem  to  have 
an  idea  that  the  precious  object  entrusted  to  their 
possession  has  delicate  and  sublimated  qualities 
which,  for  a  time  at  least,  exempt  it  from  the  common 
necessity  of  an  abundance  of  good  food.  Cases  are 
very  rare  in  which  trauma  can  be  proved  to  have 
been  the  cause  of  joint  disease,  although  many  "pre- 
vious histories"  include  a  story  of  some  injury,  from 
a  fall  or  otherwise,  which  preceded  or  accompanied 
the  first  symptoms  and  which  is  supposed  to  have 
caused  the  trouble. 

Operative  and  Mechanical  Treatment. — While  tuber- 
culosis in  the  tissue  of  a  vital  organ  generally  leads 
to  the  most  untoward  result,  the  same  affection  de- 
veloped in  a  joint  is  seldom  fatal.  With  the  favor- 
able conditions  accompanying  the  youth  and  growth 
of  the  patient  recovery  may  be  considered  assured  in 
advance.  A  method  may  be  almost  within  our  reach 
of  arresting  or  favorably  modifying  this  morbid  proc- 
ess, wherever  it  may  have  gained  a  lodgment,  and  of 
thus  prolonging  life  and  lessening  the  sum  of  deform- 
ity and  disability.  Until  this  promise  shall  have 
5 


66  GROWTH  AND  DEFORMITY. 

been  fulfilled,  however,  it  is  useless  to  undertake 
positive  treatment  of  tuberculous  joints.  In  these 
days  of  brilliant  and  painless  operations,  and  wonder- 
ful discoveries  in  physics,  it  is  not  easy  to  wait  for 
natural  repair  and  recovery.  The  most  interesting 
thing  in  surgery  is- the  arrest  of  pain  and  the  transi- 
tion from  peril  to  safety  which  often  follow  a  bold 
operation.  The  confident  surgeon  is  like  a  military 
captain  who  by  a  well-timed  advance  changes  defeat 
into  victory,  returning  with  the  priceless  trophy  of 
life  and  health.  But  this  achievement  has  not  yet 
been  seen  in  the  surgery  of  tuberculous  joints.  A 
malignant  growth  may  be  successfully  excised,  but 
not  the  involved  structures  of  such  a  joint.  The 
earlier  deposits  have  been  traced,  before  and  after  in- 
fection, and  withdrawn  by  Macnamara,  Sherman  and 
Bartow,  and  by  other  operators,  but  this  procedure  is 
not  as  yet  established.  The  initial  focus,  in  one  or 
the  other  of  the  bones  composing  the  joint,  is  pres- 
ently followed  by  others,  superficial  or  remote  from 
the  articular  surface,  some  of  them  coalescing  in 
depots  of  broken-down  tissue.  This  ambuscade 
leads  to  postponement  of  action  until  the  joint  is 
well  occupied  by  the  disease.  At  such  a  time  con- 
servatism may  seem  to  indicate  thorough  excision, 
but  with  the  risk  of  sacrificing  useful  parts  while 
overlooking  remote  points  of  diseased  action.  Among 
so  many  conditions  implying  doubt  and  undermining 


TUBERCULOUS  JOINT  DISEASE.  67 

confidence,  mechanical  surgery  happily  encourages 
a  reliance  on  wisely  planned  expectation,  which 
brings  relief  from  pain  and  gives  full  assurance  of 
timely  intervention  by  natural  reparative  processes. 

The  conservatism  which  brought  honor  to  the 
name  of  William  Fergusson  substituted  exsection  for 
amputation,  but  the  surgery  of  to-day  conserves  not 
only  the  limb  but  every  possible  structure.  All  the 
joints  and  functions  are  to  be  retained  rather  than 
surrendered,  especially  in  the  case  of  a  growing  child. 
The  fragments  are  to  be  kept  and  cherished  because 
they  will  share  in  the  development  of  the  whole 
growing  and  learning  body,  a  development  stimu- 
lated by  Nature's  ever-present  effort  to  supply  what 
is  deficient.  This  consideration  is  less  important  in 
the  treatment  of  adults,  who  may  well  desire  speedy 
recovery.  But  at  the  time  of  life  when  tuberculosis 
usually  attacks  the  joints,  prolonged  treatment  gives 
opportunity  to  direct  the  natural  growth  until  the 
"alchemy  of  patience"  reveals  ultimate  symmetry 
and  ability.  At  this  time  internal  resistance  to  dis- 
ease and  natural  efforts  to  repair  the  effects  of  dis- 
ease may  be  expected  to  promote  the  development  of 
tissue,  structure,  and  function. 

Intelligent  Expectation. — Observation  and  experi- 
ence have  matured  the  opinion  that  joint  disease 
cannot  be  cured  in  the  ordinary  sense  of  the  word. 
While  it  cannot  be  cut  short,  it  is  equally  certain  that 


68  GRO  WTH  AND  DEFORMITY. 

it  will  recover,  albeit  with  some  disability,  and  the 
physician  who  takes  that  ground  at  the  beginning  of 
such  a  case,  in  an  adult  or  in  a  child,  or  as  regards 
any  part  of  the  skeleton,  will  see  his  opinion  proved 
by  the  event.  He  will  save  his  patient  from  severe 
pain  inflicted  in  vain  efforts  to  retain  or  restore 
mobility.  He  will  probably  shorten  the  duration  of 
the  disease  and  certainly  lessen  the  degree  of  ultimate 
ankylosis  by  intelligent  efforts  to  subdue  inflamma- 
tion. To  the  method  of  treatment  thus  outlined  has 
been  applied  the  term  expectation,  a  word  which  is  not 
strictly  correct,  because  what  is  called  expectation  in 
these  cases  is  characterized  by  radical  changes  in  en- 
vironment, not  the  least  of  which  is  the  substitution 
of  rest  for  activity.  The  word  rest  does  not  mean 
very  much  if  it  implies  merely  cessation  of  work  or 
the  avoidance  of  fatigue,  but  it  means  a  great  deal 
when  applied  to  a  regulation  in  which  an  organ  is  ab- 
solutely restrained  from  its  customary  function.  A 
prescription  of  this  kind  is  common  in  medicine  and 
surgery,  but  probably  no  more  striking  example  will 
be  found  than  that  in  which  a  joint  is  not  only  pre- 
vented from  motion  but  is  also  released  from  the 
duty  of  carrying  the  weight  of  the  body. 

The  Prevention  of  Ankylosis. — At  the  first  view  it 
seems  unreasonable  to  deprive  a  joint  of  motion  in  a 
crisis  in  which  its  mobility  is  threatened  by  disease. 
It  has  been  found  difficult  to  give  to  ankylosis  its 


TUBERCULOUS  JOINT  DISEASE.  69 

proper  value  in  the  terms  of  this  therapeutical  prob- 
lem. From  a  review  of  the  morbid  anatomy  of  this 
affection,  it  is  evident  that  when  inflammatory  action 
has  swept  through  a  joint  the  results  resemble  some- 
what those  found  in  a  house  tested  by  a  conflagration. 
The  bones  are  charred,  so  to  speak,  the  articular 
surfaces  are  distorted,  the  ligaments  are  fused  and 
warped,  and  the  synovial  membranes  are  rendered  use- 
less. Normal  motion  thereafter  is  out  of  the  question. 
But  it  is  also  evident  that  the  destructive  process 
should  be  stopped  as  soon  as  possible.  Thus  far  the 
surest  method  of  subduing  inflammation  is  an  arrest 
of  function.  It  is  indeed  the  only  effective  resort. 
F"ortunately  it  is  applicable  to  a  certain  extent  in 
every  case  of  joint  disease,  and  the  point  of  practical 
and  urgent  importance  is  to  recognize  the  necessity 
of  it  at  the  earliest  possible  moment. 

Fixation  of  an  inflamed  joint  wdll  lessen  ultimate 
ankylosis  by  moderating  the  inflammation  and  abat- 
ing the  quantity  and  density  of  its  obstructiye  prod- 
ucts. It  is  credibly  stated  that  fixation  of  a  healthy 
joint  for  even  an  indefinite  time  is  powerless  to  pro- 
duce ankylosis.  It  will  interfere  with  normal  motion 
of  the  joint,  but  the  impairment  of  mobility  produced 
in  this  way  will  be  overcome  in  the  course  of  time  by 
effort  on  the  part  of  the  subject.  This  disability  is 
very  different  from  ankylosis  following  inflammatory 
disease,  which  is,  with  rare  exceptions,  permanent. 


70  GROWTH  AND  DEFORMITY. 

Let  fixation,  therefore,  be  applied  as  early  as  possi- 
ble, and  with  uncompromising  persistence,  with  the 
knowledge  that,  so  far  as  the  joint  is  healthy,  the  ap- 
plication is  harmless,  and  with  the  assurance  that,  so 
far  as  the  part  is  diseased,  fixation  will,  by  checking 
inflammation  in  the  joint,  increase  its  ultimate  mo- 
bility. It  is  notew^orthy  that,  while  the  local  environ- 
ment of  a  joint  in  the  lower  extremities  is  controlled 
by  mechanical  arrest  of  its  functions,  the  same  device 
modifies  the  general  environment  of  the  patient  by 
substituting  for  the  sick-room  a  life  of  activity  out  of 
doors. 

An  Early  Diagnosis  is  especially  valuable  in  joint 
diseases  of  the  lower  extremity  because  on  the  date 
of  the  diagnosis  depends,  more  than  in  many  med- 
ical and  surgical  emergencies,  the  character  of  the 
prognosis.  Treatment  prescribed  before  the  foci  of 
morbid  action  have  begun  a  destructive  career  under 
the  incitement  of  habitual  traumatism  should,  by 
averting  violence,  induce  resolution  with  retention  of 
motion  and  exclusion  of  deformity.  That  affections 
corresponding  to  hip  disease  and  white  swelling  of 
the  knee  are  almost  entirely  absent  from  the  upper 
extremity  indicates  that  tuberculous  deposits  are 
harmless  in  bones  that  are  exempt  from  habitual  vio- 
lence. It  is  no  time  for  timorous  hesitation  or  dread 
of  making  a  mistaken  diagnosis.  Dr.  Fayette  Tay- 
lor would  say  that  the  house  is  on  fire  or  it  is  not  on 


TUBER  CUL  O  US  JOINT  DISEA  SE.  71 

fire.  Protective  treatment,  which  is  the  first  and 
chief  requirement  of  such  cases,  is  no  real  hardship 
for  a  few  months  in  childhood  or  adolescence,  it  inter- 
feres in  no  serious  way  with  a  child's  happiness,  and 
may  secure  ability  and  symmetry  for  the  rest  of  his 
life.  To  omit  or  postpone  such  a  precaution  may 
open  a  door  to  jDermanent  disability  and  deforniity. 

Chronic  Synovitis. — When  synovitis  occurs  in  the 
course  of  tuberculous  disease  of  a  joint  it  is  second 
not  only  in  time  but  also  in  importance.  Occurring 
thus,  it  requires  no  special  attention.  No' reasons 
have  been  found  in  the  clinical  history  or  in  the  mor- 
bid anatomy  of  diseases  of  the  joints,  for  the  fear  that 
synovitis  may  "  run  into"  osteitis.  The  two  affec- 
fions  resemble  each  other  in  being  of  long  duration 
and  presenting  a  disposition  intractable  to  any  form 
of  positive  or  active  treatment.  Non-rheumatic  in- 
flammation of  the  synovial  membrane  may  interfere 
with  the  action  of  a  joint  through  excessive  effusion, 
but  the  ligaments  retain  their  properties  and  the 
neuro-muscular  element  of  inflammation  of  the  bones 
forming  a  joint  is  absent.  When  simple  or  pri- 
mary synovitis  finally  disappears  it  rarely  leaves  dis- 
ability or  deformity. 

Whether  the  joint  involved  in  tuberculosis  is  large 
and  difficult  to  treat  or  small  and  easily  controlled,  a 
long  time  will  almost  surely  be  required  for  the  res- 
toration of  the  part  to  health.     Although  the  princi- 


72  GROWTH  AND  DEFORMITY. 

pies  of  treatment  are  few  and  simple  and  easily  car- 
ried out,  their  application  does  not  often  meet  a  quick 
response.  The  beginning  of  the  process  of  repair  is 
apparently  postponed  until  the  occurrence  of  some 
general  reaction,  the  nature  of  which  is  not  clear. 

It  is  well,  therefore,  to  undertake  the  treatment  of 
such  cases  with  the  knowledge  that  recovery  will  be 
a  tedious  process.  Excepting  in  those  cases  in  which 
a  very  early  diagnosis  is  made,  the  duration  of  treat- 
ment will  probably  cover  several  years.  As  an  offset 
to  this  inconvenience,  good  functional  ability,  albeit 
with  some  lameness,  may  be  confidently  predicted. 
This  outcome  is  assured,  in  an  absolutely  favorable 
environment,  by  the  presence  of  youth  and  by  the 
assistance  derived  from  the  vital  activity  which  ac- 
companies growth.  A  splint  is  an  unwelcome  bur- 
den and  an  annoyance,  but  when  applied  to  an  adult 
it  seldom  entirely  precludes  the  pursuit  of  ordinary 
business.  Still  less  does  it  interfere  with  the  educa- 
tion and  amusements  of  a  child,  whose  buoyant  in- 
difference to  personal  inconvenience  softens  the  hard- 
ship of  mechanical  restraint.  Surely  much  can  be 
done  during  the  plastic  years  of  juvenile  growth  to 
avert  ultimate  deformity  and  disability.  . 


CHAPTER    IV. 

WHITE   SWELLING    OF    THE   KNEE. 

That  an  intimate  knowledge  of  disease  lies  at  the 
foundation  of  practice  is  not  held  by  the  faculty  alone. 
Wherever  there  is  sickness  a  physician  who  recog- 
nizes a  disease,  traces  its  origin  and  foretells  its 
course  is  at  once  credited  with  ability  to  cure  it. 
Pathology  rightly  holds  the  seat  of  honor  in  the  tem- 
ple of  ^sculapius.  But  how  changeful  is  pathology ! 
How  fickle  a  divinity!  Mr.  Adams  (1854)  wrote 
that  the  life  of  a  pathological  doctrine  was  about 
thirty  years.  We  learn,  but  with  the  prospect  of  hav- 
ing to  unlearn,  and  the  all-wise,  unwise  public  senses 
this  and  when  in  trouble  goes  doubtfully  away  "  trem- 
bling, hoping,  lingering,  flying,"  to  fanes  where  the 
divinities  are  not  only  fickle  but  meretricious.  In 
the  consideration  of  white  swelling  of  the  knee,  how- 
ever, we  recognize  a  pathological  feature  which  has 
all  the  stability  of  exact  science.  Inflammation  here 
is  prolonged  by  the  continued  use  of  the  affected 
joint,  which  goes  from  bad  to  worse  so  long  as  the 

patient  stands  and  walks. 

73 


74  GROWTH  AND  DEFORMITY. 

TREATMENT. 

Diagnosis  should  therefore  be  followed  by  release 
of  the  limb  from  duty.  Night  brings  the  recumbent 
position,  and  day  should  see  the  application  of  an 
ischiatic  crutch,  or  some  other  device  which  secures 
protection  of  the  joint  from  the  weight  of  the  body 
and  provides  for  walking  while  only  one  foot  reaches 
the  ground.  This  was  formerly  thought  to  be  im- 
possible. "  Mais  le  corps  humain  peiit-il  conserver 
pendant  des  mois  entiers  r attitude  vertical,  touchant 
le  sol  par  un  pied  seulewient  1  Evidejitment  nan  ;  c'est 
au-dessMs  de  ses  forces.  L'avejiir  nous  reserve  sans 
doute  de  grandes  surprises,  et  ce  qui  est  impossible 
auj ourd' Jitii  deviendra  peut-etre  Jacile  demain."  This 
disposition  of  the  limb,  by  improving  its  environ- 
ment, will  hasten  the  natural  reaction  tovv^ard  re- 
covery. 

Fixation. — The  evils  of  weight  bearing  being  fore- 
stalled, it  remains  to  bring  about  the  suppression  of 
motion.  Arrest  of  function  is  indicated  in  all  cases 
of  inflammation.  In  ophthalmia  light  is  excluded 
and  vision  is  placed  in  abeyance.  Adhesive  bands 
limit  expansion  of  the  chest  in  acute  pleurisy.  As 
respiratory  activity  contributes  to  the  incurabihty  of 
phthisis  pulmonalis,  occlusion  of  a  bronchus  might 
be  followed  by  limitation  of  the  area  of  serous  sur- 
faces, by  evacuation  of  the  products  of  inflammation, 


WHITE   SWELLING   OE  THE  KNEE.        75 

and  finally  by  cicatrization,  processes  which  often 
take  place  in  tuberculous  joints.  The  pain  of  an  ad- 
vanced stage  of  joint  disease  requires  arrest  of  mo- 
tion, or  fixation.  It  was  the  opinion  of  Mr.  Brodie 
that  the  efiicacy  of  "Scott's  dressing,"  a  famous 
remedy  for  white  swelling  of  the  knee,  depended  on 
layers  of  adhesive  plaster  applied  in  such  numbers  as 
to  limit  the  motion  of  the  knee,  an  effect  which 
might  have  been  produced  by  the  oxide  of  zinc  of 
Mr.  Brodie's  day  but  not  by  the  flexible  tropical 
gums  which  were  proposed  in  the  manufacture  of 
plaster  by  Mr.  Eyre  in  1848  and  perfected  by  Dr. 
Martin  in  1877. 

The  Fear  of  Ankylosis,  I'ankylophobie  of  the  French 
disputants,  still  confuses  the  treatment  of  this  affec- 
tion, as  well  as  of  other  forms  of  joint  disease.  A 
physician  naturally  hesitates  before  deciding  that  a 
child,  apparently  health3^  has  so  serious  an  affection 
as  white  swelling  of  the  knee,  and  if  he  fears  that 
resting  the  joint  will  cause  ankylosis  he  fails  to  apply 
the  most  efficient  remedy  for  inflammation  and  the 
surest  preventive  of  ankylosis.  Recognizing  the  fact 
that  impairment  of  motion  is  not  only  a  sign  of  dis- 
ease, but  also  an  effort  of  nature  to  allay  inflamma- 
tory action,  let  him  promptly  aid  this  effort  by  artifi- 
cially promoting  fixation.  Safety  lies  in  preparing 
for  impending  ankylosis  and  in  seeking  to  lessen  its 
degree  by  all  the  means  at  hand. 


76  GROWTH  AND  DEFORMITY. 

Pressure  and  Counter-pressure. — To  give  absolute 
fixation  to  the  hinge  joint  at  the  knee  the  simplest 
form  of  retentive  apparatus  is  quite  suflficient.     It 


Fig.  43. — Points  of   Pressure  and   Counter-pressure  for  Fixation  of  Knee 

Joint. 

should  make  pressure  at  the  points  indicated  by  C 
and  D  and  counter-pressure  at  A  and  B  in  Fig.  43. 
A  splint  having  this  action  is  outlined  in  Fig.  44, 
and  is  seen  applied  to  a  limb  in  Fig.  45.  A  similar 
splint  worn  by  an  adult  weighed  one  pound  and  three 
ounces.  The  firm  application  of  such  a  splint  is  at- 
tended by  what  appears  to  be  an  increase  in  the  size 

1   1 

^ LLU    \) 

|A  CO  B  ^ 

Fig.  44. — Outline  of  Brace  for  Fixation  of  Knee  Joint  (1886) . 

of  the  joint,  caused  by  repression  of  the  soft  parts 
above  and  below  the  swollen  knee.  There  is  also  an 
apparent  constriction  of  the  limb,  which  is  not  real, 


WHITE  SWELLING   OE  THE  KNEE.        77 

because  tlie  omission  to  make  pressure  from  behind 
forward  at  this  level  makes  constriction  and  inter- 
ference with  the  circulation  impossible.  Such  a 
splint  also  provides  for  the  reduction  of  flexion. 
Conforming  at  first  with  the  shape  of  the  flexed 
limb,  the  instrument  may  be  kept  tightly  buckled, 
and,  being  straightened  from  time  to  time,  it  will 
slowly,  and  with  certainty  in  ordinary  cases,  draw  the 
knee  first  into  extension  and  then  into  hyperexten- 


FiG.  45, — Brace  Applied  for  White  Swelling  of  Right  Knee.     Boy,  eight 
years  old,  io°  of  hyperextension  following  30°  of  flexion. 

sion.  This  painless  process  is  made  easy  by  the 
cheerful  interest  and  assistance  of  the  patient.  It 
illustrates  the  mobility  of  the  immobility,  so  to  speak, 
which  marks  the  early  stage  of  all  joint  disease.  In 
a  painful  stage  a  weight  and  pulley  may  be  conven- 
iently used  to  begin  the  reduction  of  extreme  flexion, 
but  a  splint  with  its  advantage  of  long  leverage  above 
and  below  dominates  the  joint  so  powerfully  that  suc- 
cess is  certain  if  flexion  has  not  become  too  resistant 
through  delav. 


7S  GROWTH  AND  DEFORMITY. 

Details  of  the  Fixative  Splint. — A  plain  bar  of  iron 
or  soft  steel  is  prepared  for  the  posterior  surface  of 
the  limb.  To  this  are  fastened  four  transverse  pieces, 
curved  to  half  encircle  the  limb.  They  are  riveted, 
the  middle  ones  to  the  posterior  and  the  others  to 
the  anterior  side  of  the  upright  bar.  The  upper  and 
lower  are  padded,  the  others  are  left  uncovered,  as 
they  do  not  touch  the  skin  and  have  the  simple  duty 
of  carrying  buckles  to  receive  pieces  of  webbing  on 
which  sliding  pads  mollify  pressure  from  before 
backward,  which  is  the  key  to  the  apparatus.  With 
soft  metal  and  simple  tools,  a  physician  remote  from 
skilful  workmen  may  give  to  his  patient  relief  and 
the  assurance  of  a  straight  limb.  The  same  results 
are  attainable  by  the  use  of  the  plaster-of-Paris  dress- 
ing, which  observes  the  same  pressure  points.  The 
plaster  splint  will  have  to  be  reapplied  occasionally 
as  the  knee  straightens  or  else  partly  divided  trans- 
versely, as  was  ingeniously  proposed  by  Dr.  V.  P. 
Gibney,  and  straightened  by  the  insertion  of  wedges 
of  increasing  size. 

Experience  has  taught  that  the  splint  is  liable  to 
be  displaced  by  gravitation,  which  may  be  opposed 
by  lacing  the  shoe  in  such  a  manner  as  to  form  from 
its  upper  part  a  cup,  or  socket,  which  receives  the 
lower  end  of  the  brace  and  keeps  it  up.  A  rotary 
displacement  is  also  sometimes  troublesome.  Reme- 
dies for  this  may  be  found  in  watchfulness  at  home, 


WHITE   SWELLING   OE  THE  KNEE. 


79 


Fig.  46. — Device  for  Keeping 
Fixative  Brace  in  Position 
(1901). 


in  experimental  changes  in  the  length  and  shape  of 
the  pieces  composing  the  splint,  or  in  the  addition  of 
buckles  and  straps  to  the  upper  and  lower  transverse 
pieces.  In  a  certain  case  the  apparatus  persistently 
sought  the  inner  side  of  the 
limb  where  it  aggravated 
a  preexisting  knock-knee. 
A  piece  of  steel  was  there- 
fore fastened,  as  seen  in 
Fig.  46,  to  the  heel  of  the 
shoe  at  a  suitable  angle, 
which  was  ascertained  by 
experiment,  and  made  to 
coalesce  with  the  upright  by  a  sliding  ring  keeper 
(seen  in  Fig,  45).  Thus  controlled  the  apparatus 
kept  its  place  behind  and  to  the  outer  side,  where  it 
opposed  both  knock-knee  and  flexion. 

Knock-knee  and  Bow  Legs. — A  similar  application 
should  be  absolutely  effective  in  the  correction  of 
rachitic  deformities  of  the  lower  limbs,  advantage 
being  taken  of  the  natural  growth,  the  increment  of 
which  should  be  enlisted  in  behalf  of  the  patient  in- 
stead of  being  allowed  to  add  to  the  trouble,  in 
further  illustration  of  the  line:  "Just  as  the  twig  is 
bent  the  tree's  inclined."  It  is  difficult  to  see  how  a 
crooked  limb  can  be  treated  with  much  success  while 
the  patient  is  on  his  feet,  since  a  large  part  of  the 
transverse  pressure  exerted  by  the  brace  must  be  ab- 


So  GROWTH  AND  DEFORMITY. 

sorbed  in  sustaining  the  weight  of  a  child  who  is  run- 
ning about  all  day.  If,  however,  the  foot  is  kept 
from  the  ground  by  suitable  apparatus,  one  foot 
being  treated  at  a  time,  or  if  the  patient  is  recumbent 
while  both  of  the  limbs  are  under  treatment,  the  chief 
mechanical  obstruction  is  removed  and  the  way  is 
cleared  for  the  positive  action  of  a  simple  but  power- 
ful lever  on  long  bones  in  a  more  or  less  plastic  and 
tractable  state.  Success  should  certainly  follow  the 
application  of  a  fixative  brace  constructed  of  soft 
metal,  or  the  use  of  any  other  suitable  method  or 
material.  To  recapitulate  the  mechanical  points: 
the  chief  direct  cause  of  the  deformity,  the  impend- 
ing weight  of  the  body,  being  removed,  the  plastic 
condition  of  the  bones  (which  is  the  indirect  cause) 
is  converted  and  inclines  the  deformity  to  yield  to 
treatment.  The  instrument  should  be  kept  on  the 
side  of  the  concavity  of  the  curve,  where  counter- 
pressure  is  made  at  distant  points  by  the  padded 
ends  of  the  brace,  while  pressure  is  made  at  the  point 
of  greatest  divergence  by  webbing  and  buckles,  the 
force  thus  applied  being  gradually  and  painlessly  in- 
creased and  the  brace  being  straightened  from  time 
to  time  as  the  limb  straightens.  When  the  deformity 
has  been  neglected  and  has  become  confirmed  by  the 
hardening  of  the  bones,  an  operation  will  be  necessary 
before  beginning  mechanical  treatment.  Extremely 
good  results  follow  the  operative  correction  of  these 


WHITE   SWELLING   OE  THE  KNEE.        8i 

deformities  by  rapid  osteoclasis  applied  at  the  upper 

part  of  the  tibia,  as  signally  demonstrated  by   Dr. 

Blanchard. 

DIAGNOSIS. 

An  early  diagnosis  of  white  swelling  of  the  knee  is 
of  great  importance.  In  the  following  case  an  early 
diagnosis  was  followed  by  a  perfect  recovery. 

Case  V.  —  Incipient  White  Swelling  of  the  Knee. 
— A  girl  seven  years  old,  and  apparently  in  perfect 
health,  had  been  limping  occasionally  for  several 
months.  The  range  of  passive  motion  was  between 
20°  and  170°  of  flexion.  Attempts  at  full  extension 
caused  reflex  resistance  and  twitching  of  the  muscles 
of  the  thigh.  There  had  been  no  subjective  symp- 
toms. The  signs  included  an  increase  of  three- 
eighths  of  an  inch  at  the  knee,  a  decrease  of  three- 
eighths  at  the  calf,  and  a  decrease  of  five-eighths  of 
an  inch  four  inches  above  the  patella.  Treatment 
was  begun  in  September,  1899.  In  the  absence  of 
pain  fixation  was  postponed,  and  weight  was  re- 
moved from  the  limb  by  an  ischiatic  crutch  with  a 
high  sole  on  the  shoe  of  the  well  foot.  At  the  end 
of  a  year  there  had  been  no  further  trouble,  the  swell- 
ing had  disappeared,  and  normal  motion  had  returned. 
In  their  new  environment  of  quiescence  the  tubercu- 
lous centres,  ignited  somewhere  in  the  cancellous 
structures  above  or  below  the  line  of  the  joint,  had 

evidently  been  walled  off  and  extinguished,  as  prob- 
6 


82  GROWTH  AND  DEFORMITY. 

ably  happens  when  they  menace  the  joints  of  pen- 
dent Hmbs,  or  other  favored  parts  of  the  skeleton. 
In  September,  1904,  four  years  after  treatment 
ceased,  there  was  no  sign  of  relapse.  Motion  was 
perfect  and  there  remained  only  a  slight  difference  in 
the  measurements  of  the  limbs.  The  benefit  derived 
from  the  successful  issue  of  this  case  was  threefold : 
Dr.  Romaine,  the  physician  who  made  the  diagnosis, 
escaped  trouble  at  a  time  when  it  has  entrapped 
many ;  the  specialist  recorded  a  case  which  did  not 
have  the  usual  residuum  of  deformity;  and  the 
little  patient  was  very  fortunate,  the  happy  results 
of  an  early  and  fearless  diagnosis. 

An  early  recognition  should,  in  truth,  be  often 
accorded  to  these  cases.  Unlike  their  situation  in 
Pott's  disease  or  in  hip  disease,  the  affected  bones  lie 
near  the  surface,  and  their  motion  (that  of  a  hinge, 
the  simplest  in  the  anatomy)  is  so  obvious  that  any- 
thing wrong  may  be  seen  at  once.  Among  the  first 
indications  are  an  inconstant  limp,  slight  increase  at 
the  knee,  and  decrease  above  and  below  the  knee  on 
comparison  with  the  other  limb,  impairment  of  pas- 
sive motion  near  the  limits  of  the  normal  range,  reflex 
muscular  action,  an  uneventful  previous  history,  and 
the  absence  of  subjective  symptoms.  When  the  dis- 
ease is  established,  its  history,  the  characteristic  white 
swelling,  and  a  tendency  to  subluxation  serve  to  dis- 
tinguish it  from  rheumatism.     A  few  years  ago  am- 


WHITE   SWELLING   OF  THE  KNEE.        83 

putation  was  a  common  resort  in  this  affection,  which 

in  a  painful  stage  leads  to  many  lapses  in  diagnosis 

through  simulation  of  malignant  disease  and  acute 

osteitis. 

RESULTS    OF   TREATMENT. 

After  white  swelling,  the  patient  must  as  a  rule 
make  himself  contented  with  a  knee  which  has  no 
motion.  With  an  ankylosed  joint  he  is  indeed  un- 
fortunate if  the  knee  is  left  in  a  condition  of  marked 
flexion.  With  this  result  he  can  of  course  sit  very 
well,  but  when  he  rises  the  limb  is  shortened  and  de- 
formed by  flexion ;  and  a  still  worse  condition  is  de- 
veloped by  the  act  of  walking,  in  which  the  weight 
of  the  body,  falling  on  a  flexed  and  stiffened  limb, 
takes  it  at  a  great  disadvantage,  so  that  locomotion 
is  almost  inevitably  attended  by  pain  and  weakness. 

Flexion  of  the  knee  is  therefore  the  chief  evil  to  be 
combated  in  this  affection.  It  attracts  attention  as 
an  early  sign  and  requires  persistent  restraint  at  all 
stages  of  treatment.  It  is  liable  to  recur  even  after 
treatment  has  ceased  and  especially  after  an  opera- 
tion has  been  performed  on  the  bones,  as  has  been 
forcibly  pointed  out  by  Dr.  Townsend. 

On  the  other  hand,  it  may  be  considered  as  a  fortu- 
nate result  if  ankylosis  has  overtaken  the  joint  when 
the  knee  is  straight  or  hyperextended.  Sitting  will 
then  be  inconvenient,  but  when  the  patient  stands 
and  walks  there  is  no  deformity  whatever  and  the 


84  GROWTH  AND  DEFORMITY. 

limb  supports  the  body  with  confident  firmness  and 
without  pain,  although  walking  will  be  somewhat  in- 
terfered with. 

In  the  complex  act  of  walking  the  foot  swings  for- 
ward to  receive  the  weight  of  the  advancing  body, 
and  this  requires  that  the  limb  be  shortened  by  slight 
flexion  of  the  knee.  When  this  is  prevented  by  a 
stiff  joint  the  gait  may  be  improved  by  raising  the 
heel  of  one  shoe  and  lowering  that  of  the  other  one. 
This  simple  device,  which  is  almost  entirely  neg- 
lected in  providing  against  this  disability,  is  especially 
applicable  when  the  affected  limb  has  been  length- 
ened by  epiphyseal  hyperaemia  in  the  acute  stage  of 
the  affection.  Some  defect  in  the  gait  will  be  pres- 
ent, but  not  enough  to  prevent  effective  walking 
and  prolonged  effort  in  locomotion. 

As  a  normal  knee  may  be  hyperextended  ten  de- 
grees and  sometimes  fifteen  degrees  hyperextension 
is  to  be  sought  rather  than  avoided  as  a  result.  In 
this  position  the  broad  articular  surfaces  are  mutually 
adapted  to  planes  of  contact  and  become  a  safeguard 
against  a  relapse  to  flexion.  Not  only  the  surfaces, 
but  also  the  ligaments  of  the  joint  may  thus  be  favor- 
ably disposed  toward  the  maintenance  of  stability  in 
weight-bearing  and  locomotion.  Leaving  out  of  con- 
sideration those  rare  cases  in  which  motion  is  quite 
normal,  or  so  wide  as  to  include  full  extension  and 
enough  flexion  to  facilitate  sitting,  the  best  result  after 


WHITE   SWELLING   OF  THE  KNEE.        85 

this  affection  is  a  knee  ankylosed  in  extension  or  hy- 
perextension.  Limited  motion  is  of  but  little  use  if 
it  does  not  include  complete  extension.  A  common 
result  is  a  diminution  of  the  circumference  of  the 
limb,  appearing  worse  than  it  really  is  from  contrast 
with  a  limb  w  hich  has  been  overworked  and  unduly 
developed.  It  has  no  effect  on  locomotor  ability. 
Subluxation,  although  a  remarkable  deformity,  is 
not  of  itself  a  seriously  disabling  incident.  If  the 
limb  recovers  fully  straightened  subluxation  throws 
the  axis  of  the  lower  bone  somewhat  behind  that  of 
the  upper  one,  but  not  enough  to  compromise  sup- 
port by  a  straight  bony  section  from  the  ground  up. 
When  abscesses  occur  they  have  the  appearance  of 
being  a  grave  complication,  but  like  those  of  hip 
disease  they  evidently  have  no  effect  on  the  duration 
of  the  affection  or  the  quality  of  its  results.  They 
may,  therefore,  be  left  to  rake  their  own  course. 
The  affected  joint  calls  for  protection  and  fixation 
while  a  good  position  is  insured  by  the  maintenance 
of  hyperextension  throughout  the  period  of  growth. 
The  want  of  adequate  attention  at  home  can  alone 
excuse  recovery  with  ankylosis  in  a  flexed  po.sition, 
as  correction  should  lie  well  within  the  power  of  so 
simple  a  device  as  a  lever.  As  in  many  other  ortho- 
paedic emergencies,  success  depends  very  much  on 
the  cooperation  of  the  patient,  or,  in  the  case  of  a 
young  child,  on  that  of  the  mother  or  of  the  nurse, 


86  GROWTH  AND  DEFORMITY. 

whom  it  is  often  not  out  of  place  to  remind  that  the 
brace  is  to  be  worn,  not  only  on  the  child's  limb,  but 
also  in  her  head. 

The  amount  of  flexion  may  be  measured  while  the 
patient  lies  on  his  well  side,  by  holding  one  arm  of 
the  goniometer  parallel  with  the  axis  of  the  shaft  of 
the  femur,  or  with  a  line  connecting  the  trochanter 
and  the  middle  of  the  knee,  and  the  other  arm  of  the 
instrument  parallel  with  the  crest  of  the  tibia,  when 
the  degree  of  flexion  may  be  read  on  the  scale.  The 
instrument  should  occupy  a  plane  parallel  with  the 
plane  of  the  leg  and  flexed  foot. 

Ankle  Disease. — Dr.  V.  P.  Gibney,  referring  to 
caries  of  the  ankle  in  children,  expresses  a  sound 
practical  opinion  as  follows :  "  The  expectant  plan, 
fully  carried  out,  assures  us  of  more  results  that  are 
perfect,  and  more  limbs  that  are  useful  without  the 
aid  of  support  than  does  any  other  plan  known  to 
the  profession."  In  the  treatment  of  disease  of  this 
joint  especial  attention  should  be  given  to  the  main- 
tenance of  protection  from  the  weight  of  the  body, 
fixation  being  sufficiently  secured  by  the  action  of  the 
muscles  of  the  limb.  A  patient  of  Dr.  Schapps, 
affected  with  disease  of  the  ankle  and  tarsus,  applied 
to  his  disabled  limb  "  an  old-fashioned  peg-leg,"  which 
shifted  his  weight  from  the  useless  foot  to  the  flexed 
knee.  He  thus  promoted  recovery  secundum  artem 
while  doing  his  duty  as  a  fireman. 


CHAPTER  V. 
TREATMENT  OF   HIP  DISEASE. 

Basis  of  Mechanical  Treatment. —  Hip  disease  seems 
to  be  rated  by  the  public  as  an  incurable  disease.  It 
is  true  that  when  it  is  fairly  established  there  is  no 
hope  of  a  return  of  the  joint  to  a  normal  condition ; 
but  it  is  far  from  being  a  fatal  disease.  It  may  be 
confidently  predicted  in  every  stage  that  the  time  will 
come  when  nature  will  rally  her  forces  and  dictate 
the  ascendency  of  repair  over  destruction.  Would 
that  it  were  possible  to  cut  short  the  morbid  process 
by  an  operation  and  thus  secure  symmetry  and  abil- 
ity! Unfortunately  the  hip  patient  cannot  be  cured 
as  if  he  had  a  calculus,  a  diseased  appendix,  or  an 
aneurismal  tumor.  And  yet  the  management  of  hip 
disease  is  by  no  means  a  matter  of  perfunctory  ex- 
pectation. Excellent  service  may  be  rendered,  with 
abundant  opportunity  for  the  exhibition  of  surgical 
qualities. 

Obviously  the  first  thing  to  do  is  to  relieve  the 
joint  from  supporting  the  weight  of  the  body.  It 
may  be  borne  in  mind  that  the  ruthless  character  of 

the  disease  is  the  result  of  untoward  mechanical  en- 

87 


88  GROWTH  AND  DEFORMITY. 

vironment.  Its  counterpart  is  not  found  in  the  up- 
per extremity,  where  the  foci  of  disease  in  the  can- 
cellous tissue  are  resolved  at  an  early  clay,  by  reason 
of  the  exemption  of  the  arm  from  the  labor  and  hard- 
ships attending  locomotion. 

Something  more  than  this,  however,  is  required  in 
the  tedious  course  of  the  disease.  There  are  periods 
in  which  the  pain  caused  by  motion  leads  the  patient 
to  steady  the  limb  by  adducting  it  against  its  fellow, 
and  even  by  flexing  it  against  the  body  where  the 
hands  may  assist  in  fixation.  In  this  emergency  me- 
chanical treatment  introduces  what  Mr.  Thomas 
termed  a  fractional  degree  of  fixation,  which  allays 
pain,  and  when  the  pain  has  ceased  enables  the  pa- 
tient to  dispose  the  limb  in  the  position  of  least 
deformity.  Mechanical  interference  should  promote 
recovery,  directly  by  inviting  resolution,  and  indi- 
rectly-by  releasing  the  patient  from  confinement  and 
invalidism  and  sending  him  out  of  doors. 

HISTORICAL   NOTES. 

Accepted  views  of  the  pathology  and  treatment  of 
hip  disease  have  greatly  changed  in  the  last  forty 
years.  A  distinct  advance  is  seen  in  a  better  appre- 
ciation of  what  can  be  done  to  modify  favorably  the 
course  and  result  of  the  disease,  which  of  late  years 
is  said  to  be  managed  rather  than  cured.     Provision 


HIP   DISEASE,   HISTORICAL   NOTES.        89 

is  made  for  promoting  the  "natural  cure"  and  for 
securing  the  minimum  of  ultimate  disability.  In  cur- 
rent discussions  the  misapplied  word  exiensiou  has 
given  place  to  (raction.  Surgeons  were  formerly 
troubled  by  spontaneous  dislocation,  which  is  now 
forgotten.  In  a  warm  discussion,  Dr.  March,  of  Al- 
bany, declared  that  it  "  seldom  or  never  took  place," 
basing  the  statement  on  "personal  examination  of 
about  forty  pathological  museums  in  this  country  and 
Europe,"  and  Dr.  George  Hayward,  of  Boston,  re- 
plied: "  It  would  require  more  specimens  than  would 
fill  forty,  or  forty  thousand,  pathological  museums  to 
convince  me  that  this  (related)  case  was  not  a  spon- 
taneous dislocation  of  the  femur." 

The  Use  of  Adhesive  Plaster  for  Traction. — The 
merits  of  this  rather  nice  question  were  presently 
lost  to  view  when  the  application  of  sticking  plaster 
replaced  the  various  painful  and  clumsy  methods 
which  had  been  necessary  whenever  it  was  desirable 
to  treat  a  broken  bone  by  laying  hold  of  the  limb  be- 
low the  seat  of  the  fracture.  Traction  was  thereafter 
applied  in  cases  of  hip  disease,  not  to  reduce  spon- 
taneous dislocation,  but  to  relieve  pain  and  promote 
recovery.  Prehension  of  the  limb  by  adhesive  plas- 
ter in  the  treatment  of  fractures  had  been  advocated 
by  Dr.  S.  D.  Gross  in  1830,  but  it  was  not  adopted 
until  attention  had  been  recalled  to  the  subject  in 
1850  by  Dr.  Josiah  Crosby,  one  of  whose  patients  de- 


90  GROWTH  AND  DEFORMITY. 

scribed  his  sensations  by  saying:  "  It  feels  as  if  my 
leg  was  in  the  mud  and  I  was  trying  to  pull  it  out." 
This  was  a  homely  but  hearty  recognition  of  the 
value  of  a  device  which  has  displaced  the  handker- 
chief knotted  about  the  ankle,  the  buckskin  gaiter 
and  similar  painful  appliances  which  were  parts  of 
the  old  long  fracture  splint,  and  which  were  doubt- 
less used  by  Mr.  Brodie  (1834)  and  others  when  they 
experimented  with  the  weight  and  pulley  in  hip  dis- 
ease. A  French  apparatus  described  in  1865  made 
traction  in  the  recumbent  position  by  pressure  against 
the  calf  of  .the  flexed  leg. 

Drs.  Henry  G.  Davis  and  L.  A.  Sayre  simultane- 
ously described  the  application  of  adhesive  plaster 
for  traction  in  hip  disease  in  i860.  The  injurious 
effects  of  muscular  action  on  the  joint,  and  their  pre- 
vention by  traction,  became  at  once  the  subjects  of 
observation  and  discussion.  Interest  was  excited  to 
such  a  degree  that  in  the  following  year  the  merits 
of  the  new  treatment  of  hip  disease  were  discussed  at 
three  successive  meetings  of  the  New  York  Acad- 
emy of  Medicine  by  Drs.  Batchelder,  Bauer,  Bron- 
son,  Gurdon  Buck,  H.  G.  Davis,  Finnell,  Holcombe, 
Krackowizer,  Miner,  Parker,  Post,  Raphael,  Sayre, 
Stevens,  Watson,  and  Wood,  and  four  years  later 
in  a  series  of  sessions  of  the  Surgical  Society 
of  Paris  by  MM.  Blot,  Boinet,  Bouvier,  Broca, 
Depaul,     Dolbeau,     Follin,    Giraldes,     Hervez    de 


HIP  DISEASE,   HISTORICAL   NOTES.        91 

Chegoin,  Le  Fort,  Marjolin,  Trelat,  Velpeau,  and 
Verneuil. 

In  these  discussions  and  in  contemporaneous  writ- 
ings the  supposed  effects  of  muscular  contraction 
received  unwonted  attention.  The  action  of  the 
powerful  muscles  of  the  hip  seemed  to  threaten  the 
integrity  of  the  cartilages  and  bones  composing  the 
joint  and  to  find  in  traction  a  worthy  opponent. 
From  these  clinical  premises,  and  too  hastily,  the 
conclusion  was  drawn  that  traction  was  curative  be- 
cause it  saved  the  joint  from  being  destroyed  by  the 
contracting  muscles.  The  advocacy  of  this  method 
by  Drs.  Davis,  Sayre,  and  Fayette  Taylor  opened  a 
field  of  observation  and  experiment  which  has  been 
under  ingenious  cultivation  ever  since.  An  incom- 
plete list  of  questions  which  have  been  answered  in 
different  ways  includes  the  following:  the  question 
of  separating  the  articular  surfaces,  of  moderating 
articular  pressure,  of  stretching  the  muscles  until 
they  were  paralyzed,  of  keeping  them  stretched  while 
motion  was  permitted  in  the  joint,  and  the  important 
but  at  first  neglected  question  of  fixation. 

The  hip  splint  was  called  by  Europeans  the 
American  splint.  As  first  described  in  i860  it  had  two 
principal  features:  a  perineal  strap,  or  crutch-head, 
for  receiving  the  weight  of  the  body,  and  sticking 
plaster  for  making  traction.  The  device  by  which 
the  body  is  supported  in  the  hip  splint  when  the  pa- 


92  GRO  WTH  AND  DEFORMITY. 

tient  is  erect  cannot  be  said  to  have  had  its  origin  in 
America.  But  the  other  distinguishing  feature  of 
the  splint,  adhesive-plaster  prehension,  was  an  im- 
provement rightly  credited  to  American  surgery. 
Thus  the  apparatus  combined  an  old  and  a  new  de- 
vice, the  latter  American,  and,  as  the  combination 
was  made  here,  European  writers  courteously  named 
the  method  and  sphnt  American. 

Many  changes  have  been  proposed  in  the  appa- 
ratus. In  the  "short  hip  splint"  the  upright  ex- 
tended only  to  the  middle  of  the  leg,  and  the  pa- 
tient's foot  was  allowed  to  rest  on  the  ground.  It 
was  thought  that  when  the  instrument  was  keyed  up 
the  plaster  would  have  sufficient  strength  and  adhe- 
siveness to  resist  the  weight  of  the  body  and  prevent 
it  from  making  pressure  on  the  joint.  When  this 
was  found  to  be  a  vain  hope,  the  apparatus  was  made 
to  reach  the  ground  and  the  weight  of  the  body  was 
transferred  from  the  plasters  to  the  ischium,  prac- 
tically producing  a  crutch  applied  under  the  leg 
instead  of  under  the  arm.  Aside  from  this,  no 
important  change  has  been  made.  The  splint  has 
been  modified  experimentally  for  the  enforcement 
of  extension,  abduction,  motion  without  friction, 
relief  from  articular  pressure,  and  counteraction  of 
the  circumarticular  muscles.  The  attainment  of 
these  objects  may  or  may  not  have  been  useful  in 
certain  stages.     Experience  has  shown  that  certain 


TREATMENT  OF  HIP  DISEASE.  93 

effects  supposed  to  be  produced  were  impossible,  and 
others  which  might  have  been  practicable  were  un- 
necessary. The  value  of  the  American  method 
would  perhaps  have  been  more  widely  recognized 
even  than  it  has  been  if  too  much  had  not  been 
hoped  from  it.  Traction  simply  stays  the  joint  and 
relieves  pain,  and  the  perineal  support  effectively 
protects  it  from  the  traumatisms  of  standing  and 
walking,  while  the  patient  runs  about  and  follows 
the  ordinary  pursuits  of  his  time  of  life  for  the 
months  and  years  required  to  bring  about  recovery, 
with  restoration  of  ability  and  symmetry,  so  far  as 
miay  be. 

BASIS  OF  TREATMENT  BY  THE  SPLINT. 

There  are  reasons  for  withholding  assent  from  an 
opinion  of  the  early  advocates  of  this  method,  that 
traction  owed  its  ef^ciency  to  its  ability  to  overcome 
the  muscles  which  were  thought  to  be  destroying  the 
joint  by  their  reflex  contraction.  This  presupposed 
an  inadmissible  vicious  circle,  in  which  the  destruc- 
tive process  excited  muscular  action,  while  muscular 
action  aggravated  the  destructive  process.  Accord- 
ing to  one  theory,  the  muscles  should  be  stretched  by 
the  elastic  power  of  India-rubber  straps  until  they 
were  paralyzed.  This,  however,  was  not  likely  to 
happen  because  opposition  and  exercise  develop  in- 


94  GROWTH  AND  DEFORMITY. 

stead  of  exhausting  the  power  of  muscular  fibres, 
which  would  hardly  surrender  their  supreme  endow- 
ment of  contractility  to  anything  short  of  rupture 
or  degeneration.  If,  on  the  other  hand,  the  traction 
applied  were  inelastic  and  unyielding,  the  stretching 
which  it  could  give  to  the  muscles  would  soon  have 
been  arrested  by  the  ligaments,  and  in  any  event  it 
would  have  been  insignificant  in  view  of  the  elonga- 
tion to  which  they  had  been  accustomed  in  the  alter- 
nations of  contraction  and  relaxation.  According  to 
another  theory  the  muscles  might  be  kept  from  in- 
creasing joint  pressure  by  a  splint  making  traction 
and  permitting  motion  of  the  joint  at  the  same  time; 
but  insurmountable  difficulty  was  found,  in  trying  to 
keep  such  a  force  in  action  through  the  variations 
and  combinations  of  extension,  flexion,  abduction, 
and  adduction.  If,  indeed,  traction  could  have  been 
applied  directly  to  the  bone  without  the  intervention 
of  the  soft  parts  it  possibly  might  have  been  in  a  posi- 
tion to  counteract  the  muscles.  It  had  to  be  applied, 
however,  to  the  skin,  which  was  but  an  elastic  en- 
velope of  a  mass  composed  largely  of  relaxed  muscu- 
lar and  yielding  connective  tissue.  These  interest- 
ing speculations  were  prompted  by  what  was  believed 
to  be  a  most  important  discovery.  When  traction 
was  applied  by  a  splint  to  a  painful  joint  the  appear- 
ance certainly  was  that  of  muscles  subjected  to  coun- 
teraction, and  when   relief  from   pain   immediately 


TREATMENT  OF  HIP  DISEASE.  95 

followed,  the  inferences  were  natural  that  muscular 
action  was  a  mischievous  factor  and  that  it  was  suc- 
cessfully overcome  by  traction.  The  enthusiasm 
excited  by  such  signal  relief,  produced  by  means  so 
simple,  is  reflected  in  the  writings  of  those  who  first 
witnessed  the  seeming  miracle. 

The  facts  of  morbid  anatomy  indicate  that  the  de- 
struction of  the  joint  is  not  caused  by  muscular  con- 
traction. If  it  were,  the  evidences  of  friction  would 
be  seen  in  the  acetabulum  as  well  as  on  the  head  of 
the  femur.  In  a  large  proportion  of  the  tabulated 
cases,  however,  the  acetabulum  is  unaffected.  In 
the  earliest  incipiency  of  the  disease  the  lesion  (as 
is  shown  in  Figs.  47,  48,  and  49)  is  in  the  cancellous 
tissue,  which  is  remote  from  possible  injury.  In  a 
later  stage,  when  ulceration  appears,  it  is  not  on  areas 
exposed  to  friction  but  chiefly  on  the  neck  of  the 
femur,  as  in  Figs.  50  and  51,  and  when  the  disease  is 
in  full  possession  it  proceeds  from  within  outward, 
as  in  Figs.  52,  53,  and  54.  It  is  not  uncommon  in- 
deed to  find  specimens  bearing  evidences  of  direct 
injury,  but  as  many  patients  are  active  on  their  feet 
without  the  protection  afforded  by  apparatus,  the 
destructive  pressure  is  as  likely  to  have  come  from 
weight  as  from  muscular  contraction.  Fig.  55  shows 
a  specimen  after  an  operation  in  the  third  stage.  In 
this  case  an  unaffected  area  appears  on  the  summit  of 
the  head,  which  is  the  part  most  likely  to  feel  the  in- 


96 


GROWTH  AND  DEFORMITY. 


jurious  effects  supposed  to  be  produced  by  muscu- 
lar action.  In  this  concise  review,  evidence  has  not 
been  found  of  the  destructive  agency  of  the  muscles. 


Fig.  47. 


Fig.  48. 


Figs.  47,  48. — Specimen  from  Boy  Four  Years  Old.     Duration  of  disease, 
four  montlis.     Deatli  from  tubercular  meningitis.     (Fricke,  1833.) 


Fig.  49.  Fig.  50. 

Fig.  49. — Exsection.  Recovery.      (Vollcmann,  1S79.) 

Fig.    50. — Exsection.  Girl  eleven  years  old.      Duration,   two  years.      (T. 
Holmes,  i86g.) 


TREATMENT  OF  HIP  DISEASE. 


97 


The  diseased  bones  are  highly  vascular,  and  fragile 
to  such  a  degree  that  an  exploring  needle  has  been 
used  in  diagnosis.     They  might  well  be  expected  to 


Fig.  51. — Specimen  from  Boy  Five  Years  Old.     Duration,  several  months. 
Death  from  tubercular  meningitis.     (Barwell,  1881.) 


Fig.  52. 


Fig.  53. 


Figs.  52,  53. — Boy,  Eight  Years  Old.      Duration,  several  years, 
from  intercurrent  disease.     (V.  P.  Gibney,  1878.) 


Death 


show  the  effects  of  severe  pressure,  since  healthy 
vertebral  tissue  yields  to  the  impact  of  an  aortic 
aneurysm.    If  the  force  projected  in  the  manner  sup- 


98  GROWTH  AND   DEFORMITY. 

posed  were  such  a  menace  as  to  require  the  exhibi- 
tion of  traction  carried  to  the  not  uncommon  meas- 
ure of  fifteen  pounds,  it  should  lead  to  perforation 


Fig.  54 


Fig.  54. — Exsection.     (Volkmann,  1879.) 

Fig.  55. — ^Exsection.      Recovery.     Boy  fourteen  years  old.      (L.  A.  Sayre, 

1S76.) 

of  the  floor  of  the  acetabulum  and  invasion  of  the 
pelvic  cavity  by  the  decapitated  femur. 

Reasons  for  Applying  Traction. — It  is  not  necessary 
to  go  very  far  to  find  good  and  sufficient  reason  for 
this  procedure.  If  traction  secures  fixation  of  a  joint 
so  intractable  as  the  hip  its  application  is  amply  jus- 
tified. To  immobilize  the  hip  has  always  been  a 
dif^cult  problem.  Mr.  Charles  Bell  said :  "  No  in- 
strument has  ever  been  effectual  in  keeping  the  thigh 


TRACTION  IN  HIP   DISEASE.  99 

and  trunk  fixed."  Desault  held  the  opinion  that  trac- 
tion made  by  his  long  fracture  apparatus  immobilized 
all  the  joints  from  the  hip  to  the  tarsus.  His  splint 
consisted  "  in  taking  the  points  of  extension  above, 
on  the  tuberosity  of  the  ischium  and  below  on  the 
malleoli;  in  securing  the  straps  or  rollers  for  making 
extension  on  the  two  ends  of  a  strong  splint  placed 
along  the  outer  side  of  the  limb,  and  converting,  so 
to  speak,  the  pelvis,  the  thigh,  the  leg,  and  the  foot 
into  one  entire  and  solid  piece."  Lesauvage  wrote 
that  one  of  the  objects  of  continued  extension  in  hip 
disease  was  to  prevent  motion.  Mr.  Listen,  dis- 
paraging the  weight-and-pulley  experiments  of  Mr. 
Brodie,  said :  "  All  this  may  amuse  the  patient's  mind, 
perhaps,  but  I  do  not  think  any  good  can  come  from 
it  further  than  preventing  motion."  M.  Philipeaux 
writes  that  traction  may  be  employed  to  secure  im- 
mobility of  the  limb.  Dr.  Fayette  Taylor  referred 
to  "  the  quiet  fixation  of  the  joint  which  the  splint 
has  been  a  convenient  means  of  accomplishing."  Dr. 
Louis  Bauer  said :  "  Whatever  benefit  I  have  derived 
from  it  (extension)  is  unquestionably  due  to  its  fixing 
the  affected  articulation."  Mr.  Thomas  wrote  that 
extension  involves  unavoidably  "  a  fractional  degree 
of  fixation."  Dr.  Yale  writes:  "  When  the  muscular 
spasm  is  urgent,  fixation  cannot  be  secured,  save  by 
the  use  of  force  as  constantly  acting  as  that  which  is 
to  be  overcome,  and  the  agent  best  adapted  to  this 


100  GROWTH  AND  DEFORMITY. 

purpose  is  traction."  Dr.  Wyeth  writes:  "Exten- 
sion is  made  by  means  of  the  screw  key,  until  there 
is  freedom  from  pain  and  a  comfortable  fixation  of 
the  limb."  Dr.  Shaffer  writes :  "When  traction  ex- 
ists the  patient  has  the  advantage  of  that  peculiar 
and  perfect  immobility  which  the  extension  of  the 
long  hip  splint  affords." 

Function  of  the  Muscles. — The  muscles  have  a  two- 
fold function :  they  move  the  joint  and  they  fix  the 
joint.  If  their  action  is  at  a  point  remote  from  the 
centre  of  gravity  of  the  body,  they  are  more  effective 
in  both  motion  and  fixation  because  of  the  dispropor- 
tion between  the  part  above  and  that  below  the  point 
of  motion.  There  was  philosophy,  as  well  as  humor, 
in  Dundreary's  witticism:  "Why  does  a  dog  waggle 
his  tail?  Because  the  tail  can't  waggle  the  dog." 
This  action  is  not  only  motion,  but  also  arrest  of  mo- 
tion, right  and  left.  It  follows  that  if  the  part  below 
is  more  easily  moved  on  account  of  its  comparative 
lightness,  it  is  also  more  easily  fixed  for  the  same  rea- 
son. This  makes  joint  disease  less  serious  the  nearer 
it  is  to  the  distal  phalanges.  Aside  from  the  insta- 
bility of  the  ball  and  socket  at  the  hip,  if  the  whole 
limb  were  no  heavier  than  the  foot  hip  disease  would 
not  be  more  serious  than  ankle  disease.  Mr.  Hilton 
related  a  case  in  which  the  patient,  who  had  hip  dis- 
ease and  white  swelling  of  the  knee  of  the  same  limb, 
recovered  rapidly  from  the  former  after  amputation 


TRACTION  IN  HIP  DISEASE.  loi 

above  the  knee.  His  comment  was:  "  In  fact,  I  may 
say  that  the  hip  joint  was  cured  by  cutting  off  the 
leg." 

It  may  also  be  borne  in  mind  that  the  hip  is  pecul- 
iarly disturbed  by  the  movements  of  other  joints. 
In  the  words  of  Charles  Bell:  "There  is  no  rest  to 
it ;  every  motion  of  the  body  may  be  said  to  be  ac- 
companied with  a  movement  of  the  head  of  the  femur 
within  its  socket;  even  if  the  arm  be  raised,  there  is 
a  change  in  the  centre  of  gravity  of  the  body,  and 
the  trunk  must  be  poised  anew  upon  the  hip,  as  the 
centre  of  all  our  motions.  It  is  remarkable  how  the 
slightest  degree  of  movement  in  another  part  of 
the  body  is,  as  it  were,  necessarily  accompanied  with 
a  motion  of  the  surfaces  of  those  bones  which  com- 
pose the  hip-joint.  If  ever  you  should  see  a  patient 
suffering  with  acute  inflammation  of  the  hip,  you 
will  see  the  proof  of  this ;  for  every  motion  of  the 
body  gives  extreme  pain,  and  proves  an  additional 
source  of  excitement  and  inflammation.  It  is  this 
consideration  which  leads  us  to  understand  the  diffl- 
culty  of  curing  the  disease." 

A  retentive  splint,  so  useful  in  the  surgery  of  frac- 
tures, is  at  a  disadvantage  when  applied  to  the  hip 
on  account  of  the  short  lever  above  the  seat  of  mo- 
tion, extending  only  from  the  acetabulum  to  the  crest 
of  the  ilium.  If  it  were  equal  to  that  below,  or  if  the 
pelvis  and  vertebrae  w^ere  replaced  by  a  long  bone. 


102  GROWTH  AND  DEFORMITY. 

retention  would  be  as  easy  as  at  the  knee.  In  like 
manner  the  treatment  of  Colles'  fracture  of  the  wrist 
may  be  simplified  in  the  imagination  by  fusing  into 
one  piece  the  parts  of  the  skeleton  below  the  frac- 
ture. A  toy  cup  and  ball  furnishes  an  illustration. 
The  long  handle  of  the  cup  gives  more  than  enough 
leverage,  but  a  retentive  contrivance  would  fail  un- 
less additional  leverage  were  given  to  the  ball  by  driv- 
ing a  stick  into  it  to  serve  as  a  handle  or  lever. 

Correlation  of  Traction  and  Fixation. — In  the  pres- 
ence of  the  mechanical  difficulties  which  hamper 
fixation  of  the  hip-joint  by  retentive  means,  hopeful 
resort  may  be  had  to  traction.  Simple  Retention^ 
however,  has  been  applied  to  the  hip,  and  with  con- 
siderable success,  notwithstanding  its  disadvantage 
of  short  leverage.  This  is  true  especially  in  the  use 
of  the  splint  invented  by  Mr.  Thomas.  Other  ex- 
amples are  also  found.  Dr.  Coates,  referring  to  Dr. 
Physick's  hollow  carved  wooden  splint,  which  ex- 
tended from  the  malleoli  to  the  middle  of  the  thorax 
and  included  one-half  of  the  trunk,  wrote :  "  The  pa- 
tient frequently  stated  that  he  had  obtained  in  the 
night  following  its  application  sounder  sleep  than  for 
many  weeks,  or  even  months,  previously."  M.  Bon- 
net wrote :  "  I  have  seen  the  pain  and  inflammation 
disappear  as  soon  as  the  limb  was  brought  into  posi- 
tion and  held  immovable  "  by  le grand appareil,  which 
included  two-thirds  of  the  circumference  of  the  lower 


TRACTION  IN  HIP  DISEASE.  103 

limbs  and  trunk.  "  From  the  moment  of  appliceition 
the  pains  diminished."  M.  Phihpeaux,  relating  his 
experience  with  the  same  apparatus  wrote :  "  The 
next  morning  I  learned  that  the  patient,  who  had 
moaned  incessantly  the  night  preceding  the  applica- 
tion, had  slept  calmly  for  four  hours."  Mr.  Noble 
Smith,  referring  to  Mr.  Chance's  splint,  which  in- 
cluded the  thigh  and  a  large  part  of  the  trunk,  speaks 
of  "  the  almost  immediate  relief  from  pain  which  the 
patient  experiences  when  the  splint  is  applied."  On 
the  other  hand  a  number  of  instances  may  be  cited 
of  the  remarkable  relief  from  pain  produced  by  Trac- 
tion. It  was  observed  by  M.  Blandin  that,  on  the 
application  of  extension  and  traction,  the  acute  pains 
of  hip  disease  "  disappeared  as  if  by  enchantment." 
Mr.  Brodie  described  a  weight  and  pulley  applied  "  in 
line  with  the  thigh  bone"  and  added:  "  It  is  aston- 
ishing what  comfort  I  have  known  this  to  give 
the  patient."  Gustav  Ross  wrote  that  when  the 
weight  and  pulley  were  used  in  the  hip  disease  of 
children  "  the  pain  lessens  astonishingly."  Dr.  Wat- 
son, of  the  New  York  Hospital,  relating  a  case  of 
acute  hip  disease  when  the  new  method  of  treatment 
was  discussed  by  the  Academy  of  Medicine,  said :  "  I 
had  hardly  put  on  the  counter-extension  before  the 
girl  was  entirely  free  from  pain.  It  operated  beauti- 
fully and  instantly."  Dr.  E.  S.  Cooper,  of  California, 
describing  an  ingenious  device  for  traction,  wrote: 


104 


GROWTH  AND  DEFORMITY. 


"  Often  have  patients  slept  better  the  first  night  after 
its  appHcation  than  they  had  for  many  months  previ- 
ously." When  pain  is  thus  seen  to  be  controlled 
equally  by  tractive  and  retentive  apparatus,  the  cor- 
relation of  traction  and  retention  is  evident. 

Character  of  the  Pain. — It  has  been  thought  that 
relief  follows  too  promptly  to  be  rightly  considered 
as  the  ^result  of  purely  mechanical  interference.  It 
may  be  said,  however,  that  the  pain  of  hip  disease  is 
composed  largely  of  apprehension  and  fatigue,  both 
mental  and  muscular,  attending  prolonged  voluntary 
and  reflex  efforts  to  prevent  motion,  with  sharp  ac- 
cessions when  motion  is  made  inadvertently,  or  as 
the  patient  starts  when  falling  to  sleep.  Such  pain 
is  instantly  relieved  and  prevented  by  whatever  pro- 


"Xb- 


A 


B 


C 


Fig.  56.  —  Fixation  by  Weight  and  Pulley. 

tects   the  joint  from   disturbance.     In  some  cases 
severe  pain,  not  controlled  mechanically,  probably 
indicates  a  collection  of  matter  in  the  bony  cells. 
That  traction  secures  fixation  is  capable  of  demon- 


TRACTION  AV  HIP  DISEASE. 


105 


stration.  Take  two  iron  rods,  A  B  and  B  C  in  Fig. 
56,  resembling  two  links  of  a  surveyor's  chain.  If 
the  free  end  of  one  is  attached  to  a  wall  while  trac- 
tion is  applied  by  a  weight  and  pulley  to  the  free  end 
of  the  other,  mobility  is  seen  to  be 
absent  from  their  joint  so  long  as 
adequate  traction  is  maintained. 
This  explains  the  action  of  "  Buck's 
extension"  in  fractures.  To  say 
that  traction  stretches  the  muscles 
until  they  act  directly  as  retentive 
splints  overlooks  the  lengthening 
which  belongs  to  them  in  custom- 
ary relaxation.  The  fixation  thus 
produced  in  the  two  links  of  chain 
by  a  weight  and  pulley  may  readily 
be  disturbed  by  a  competent  force, 
but  if  a  tractive  splint  be  substituted  for  a  weight 
and  pulley  the  result  is  remarkably  firm  and  inde- 
structible. 

When  the  splint  is  applied  to  a  patient  fixation  is 
promoted  also  by  the  action  of  what  is  known  in 
mechanics  as  a  brake.  The  perineal  strap  retards 
motion  by  making  friction  on  the  region  to  which  it 
is  applied.  In  Fig.  57  the  circle  represents  the  pel- 
vis, the  point  A  the  joint,  A  B  the  femur  coalescing 
with  the  upright  of  the  splint,  and  C  D  the  strap,  prac- 
tically of  one  piece  with  A  B  applied  to  the  ischium. 


B 

Fig.  57. — A  Mechani- 
cal Brake  (1883). 


io6  GROWTH  AND  DEFORMITY. 

When  traction  is  enforced  by  the  rack  and  pinion, 
motion  at  A  is  retarded  by  friction.  The  spUnt  also 
acts,  although  at  a  disadvantage,  as  a  retentive  appa- 
ratus, being  assisted  in  this  function  by  restraints  ap- 
plied above  the  knee,  which  limit  motion  at  the  knee 
and  promote  coalition  of  the  thigh  and  the  upright. 

Paradox  in  the  Treatment  of  Joint  Disease  and  Frac- 
ture.— The  idea  that  hip  disease  and  fracture  of  the 
femur  require  similar  treatment  is  not  very  new  in 
medical  literature.  In  1779  David  de  Rouen  wrote 
that  "  notable  cures  of  disease  of  the  joints  are  to  be 
effected  by  allowing  the  parts  to  remain  undisturbed 
in  splints,  as  in  the  treatment  of  fractures."  M.  Bon- 
net presented  le  grand  appareil  for  hip  disease  in 
1845,  after  having  described  it  in  1839  as  a  fracture 
apparatus,  and  the  complicated  method  of  M.  Martin 
was  prescribed  in  1850  for  fracture  and  in  1865  for 
coxalgia.  Mr,  Ford  (1810)  compared  hip  disease  with- 
out sinuses  to  a  simple  fracture,  and  Mr.  Brodie  made 
this  comment :  "  If  the  cartilage  be  extensively  de- 
stroyed without  suppuration,  the  case  may  be  com- 
pared to  one  of  simple  fracture ;  and  if  there  be  sup- 
puration, it  may  be  compared  to  one  of  compound 
fracture,  a  statement  which  led  Dr.  March  to  ask 
(1853):  "  If  there  be  some  analogy  between  the  con- 
dition of  the  hip-joint  in  morbus  coxarius  and  frac- 
ture of  the  neck  of  the  bone,  why  should  there  not 
be  some  similarity  in  the  mode  of  treatment?"     As 


THE  HIP   SPLINT.  107 

if  to  enforce  his  view,  he  invented,  and  described 
with  a  cut,  a  hip  splint  which  resembled  in  its  action 
the  long  fracture  apparatus  of  Desault.  There  is  an 
obvious  incongruity  in  the  proposition  that  the  same 
treatment  is  applicable  in  an  emergency  in  which  ar- 
rest of  motion  is  essential  to  recovery,  and  in  an  af- 
fection in  which  mobility  is  earnestly  desired.  An 
escape  from  this  predicament  lies  in  accepting  the 
proposition  that  when  a  joint  is  inflamed  ultimate 
mobility  is  to  be  sought  by  arresting  motion  and  thus 
minimizing  the  products  of  inflammation. 

DETAILS   OF   TREATMENT   BY  THE   SPLINT. 

The  upright  of  the  hip  spint  is  usually  made  round 
in  shape,  as  is  shown  in  Figs.  58  and  61.  The  spHnt 
shown  in  Figs.  59  and  60  is  flat,  the  metal  being  dis- 
posed in  the  direction  of   the  strain.     The  lateral 


Fig.  58.- — Round  Hip  Splint  and  Knee-piece  (iS8o). 

Strain  falls  with  exceptional  severity  on  the  splint 
when  two  perineal  straps  are  in  use.  But  with  a  sin- 
gle strap,  the  weight  falls  almost  vertically  on  the  up- 
right, and  a  lateral  distribution  of  the  metal  is  unnec- 


io8 


GRO  WTH  AND  DEFORMITY. 


essary.     The  splint  may  then  be  made  from  steel 
tubing  as  seen  in  Fig.  6i,  a  number  of  bars  of  vari- 


FlG.  60. 


Fig.  61. 


Fig.  59. 

Fig.  59.— Flat  Hip  Splint  (1885).        Fig.  60.— Flat  Hip  Splint  Complete. 
Fig.  61. — Steel  Tube  Splint  (1903). 

ous  lengths  being  made  for  each  barrel  to  meet  the 
requirements  of  longer  and  shorter  limbs.  Some 
advantage  is  gained  by  giving  the  length  to  the  bar 


THE  HIP  SPLINT.  109 

rather  than  to  the  barrel,  an  arrangement  seen  in 
Figs.  59,  60,  and  61,  which  brings  the  key  and  the 
bulk  and  weight  of  the  apparatus  near  the  body, 
where  they  are  more  conveniently  managed  than 
when  near  the  foot.  The  splint  shown  in  Fig.  60 
weighs  from  two  pounds  to  four  pounds  and  eight 
ounces.  The  different  parts  of  the  splint  and  their 
uses  are  well  known.  The  knee  piece  is  of  soft 
metal  for  bending  to  fit  the  limb  and  is  adjustable 
vertically  on  the  upright.  It  limits  motion  at  the 
knee  and,  pari pass2i,  at  the  hip.  The  pelvic  band  is 
a  nearly  semicircular  bar  of  inflexible  steel,  adjust- 
able at  the  selected  angle,  usually  a  right  angle, 
where  it  is  immovably  fixed  by  a  bolt  and  nut.  If 
extreme  flexion  is  present  this  band  should  take  a 
marked  angle.  The  screw  holes  at  its  ends  are  "  up- 
set" on  the  inner  side  before  the  band  is  covered 
with  Vulcanized  rubber,  or  wound  with  adhesive  plas- 
ter to  prevent  rust,  and  Canton  flannel  or  silk  cut 
bias  in  strips.  The  perineal  strap  is  of  webbing, 
doubled  for  a  heavy  patient,  softened  with  some 
woollen  stuff,  and  covered  with  Canton  flannel.  It 
may  be  washed  and  has  a  loop  for  buttoning 
on  the  ends  of  the  pelvic  band  over  the  screw 
heads. 

Key  to  the  Application. — The  determination  of  the 
length  of  the  strap  is  the  key  to  the  successful  use  of 
the  splint.     If  the  perineal  strap  is  too  long  it  allows 


no 


GROWTH  AND  DEFORMITY 


the  pelvic  band,  when  weight  is  thrown  on  the  sphnt, 
to  rise  to  such  a  level  as  to  abrade  the  skin  covering 
the  anterior  superior  spinous  process  of  the  ilium, 
the  level  of  which  is  indicated  by  the  transverse  line 
drawn  in  Fig.  63.  If,  on  the  other  hand,  the  perineal 
strap  is  too  short,  it  holds  the  band  down  where  it 
makes  intolerable  pressure  on  the  pubic  crest.  It 
would  seem  that  a  transverse  depression  had  been 

provided  between  these  two 
levels,  in  which  pressure  is 
harmlessly  received  by  the 
abdominal  wall.  It  is  well 
to  ascertain  by  experiment 
the  right  length  of  the  strap, 
and  then  to  attach  it  by 
loops,  instead  of  by  buckles 
which  permit  careless  ad- 
justment. If  the  strap  is  a 
simple  ischiatic  support  it 
may  be  left  on  the  band 
and  the  apparatus  may  be 
pulled  on  over  the  foot.  A  band  which  is  held  at  a 
low  level  on  the  pelvis  by  a  short  strap  implies  a 
short,  light,  and  convenient  upright,  and  the  band 
can  be  smaller  than  it  would  have  to  be  if  worn  with 
a  long  strap  at  the  level  of  the  iliac  crest  or  ribs. 
Another  advantage  will  appear  in  the  fact  that  a 
band  thus  kept  in  its  proper  place  will  be  below  a 


Fig.  62. — Wooden  High  Sole. 


THE   HIP   SPLINT. 


Ill 


spinal  brace  or  plaster  jacket  if  concurrent  disease  of 
the  spine  requires  treatment. 


Fig.  63.  Fig.  64. 

Figs.  63,  64. — Splint  Applied  for  Protection,  Weight  of  Body  Thrown  Al- 
ternately on  the  Splint  and  on  the  Well  Foot,  Carrying  Strap  Relaxed 
and  Tense.  Pelvic  band  kept  below  level  of  iliac  spine  by  short  seat 
strap. 

To  Give  Protection  the  upright  should  be  of  such 
a  length  as  to  keep  the  heel,  but   not   necessarily 


112 


GROWTH  AND  DEFORMITY 


the  toe,  clear  of  the  ground.  Concussion  passes 
from  the  heel  directly  to  the  diseased  joint,  but  from 
the  toe  indirectly,  and  softened  by  the  elastic  action 
of  the  muscles  moving  the  tendo  Achillis.  A  carry- 
ing strap  (seen  in  Figs. 
63  and  64)  is  made  from 
a  piece  of  wide  webbing 
which  passes  under  the 
head  of  the  upright  and 
crosses  the  opposite 
shoulder  to  buckle  in 
front  at  the  convenience 
of  the  patient.  As  the 
splint  extends  quite  a 
distance  below  the  foot, 
the  well  foot  will  have  a 
high  sole,  a  convenient 
form  of  which  is  seen 
in  Fig.  62.  Thus  pro- 
tected, the  affected  limb 
is  a  pendent  member, 
the  perineal  strap  being 
practically  a  crutchhead. 
Dr.  Fayette  Taylor 
wrote  that  "  the  patient 

Fig.  65. — Splint  Applied  for  Traction. 

sits  firmly  upon  the  pad- 
ded strap."  Dividing  his  weight  between  the  sound 
limb  and  the  splint,  he  doubtless  has  a  composite 


THE  HIP   SPLINT  113 

sensation  of  standing  and  sitting.  In  progression 
weight  is  thrown  alternately  on  the  splint,  as  in  Fig. 
63,  and  on  the  well  foot,  as  in  Fig.  64.  It  is  not  en- 
tirely fanciful  to  say  that  the  patient  is  sitting  while 
walking.  It  is  related  that  a  little  boy,  to  whom  the 
splint  was  applied,  walked  about  exclaiming:  "I'm 
sitting  down."  When  tired  a  patient  may  lean  against 
some  support  and  rest  by  sitting  on  the  strap.     Mr. 


B  '^s— '  ^^ — s^'c 

Fig.  66. — Application  of  Adhesive  Plaster  to  Limb  (1887). 

Adams,  returning  to  London  in  1877,  described  chil- 
dren under  treatment  for  hip  disease  walking  about 
the  streets  and  "  enabled  to  get  in  and  out  of  the 
tramway  cars  without  difficulty." 

To  Make  Traction,  strips  of  adhesive  plaster  may 
be  attached  to  opposite  sides  of  the  limb  and  pro- 
tected by  a  reversed  bandage.  Drawing  the  turns  of 
a  roller  and  passing  it  under  the  limb  are  painful  to 
a  sensitive  joint,  from  the  necessity  of  raising  the 
limb.  This  difficulty  was  overcome  in  Dr.  Fayette 
Taylor's  practice  by  the  use  of  a  legging  of  twilled 
muslin,  seen  in  Fig.  65.  It  was  slipped  into  place 
and  laced  without  disturbing  the  limb.  Dermatitis 
may  appear  under  the  plaster  as  the  result  of  re- 
tained moisture,  as  it  does  under  a  continued  poul- 


114  GROWTH  AND  DEFORMITY. 

tice.  It  is  said  that  a  "wet  pack"  is  sometimes 
artfully  claimed  to  have  a  curative  effect  on  rheu- 
matism and  other  complaints  by  drawing  morbid 
matter  to  the  surface  in  the  shape  of  an  eruption. 
The  skin  will  escape  irritation  if  one  strip  is  applied 
antero-laterally,  as  at  A  in  Fig.  66,  and  the  other 
postero-laterally,  as  at  B,  leaving  fresh  areas  for  the 
reception  of  succeeding  strips  at  C  and  D. 

When  prehension  of  the  limb  is  thus  secured  the 
leather  straps  seen  in  Figs.  60  and  65  may  be  buckled 
to  the  plasters  and  the  ischiatic  strap  adjusted  on 
the  pelvic  band.  Traction  may  then  be  made  by 
propelling  the  rack  with  the  pinion.  If  a  high  de- 
gree of  traction  is  employed  in  warm  weather,  or  in 
a  hot  room,  the  plaster  will  gradually  slip  down, 
when  the  leather  straps  may  be  buckled  shorter  and 
the  plasters  renewed  sooner.  Their  removal  may  be 
facilitated  with  naphtha  or  some  other  solvent.  A 
light  plaster  may  be  reenforced,  before  the  buckles 
are  stitched  or  eyeletted  in  place,  by  tape  sewn  on  in 
parallel  lines  which  will  not  prevent  the  removal  of 
the  facing  just  before  application.  Gum  collecting 
on  the  needle  of  the  machine  may  require  a  drop  of 
oil. 

Traction  is  especially  applicable  to  the  victim  of 
an  advanced  stage.  Mr.  Hancock's  description  in- 
cluded these  words :  "  Look  at  a  patient  wasted  to  a 
shadow,  confined  to  his  bed  for  months  and  in  the 


THE  HIP   SPLINT.  115 

last  stage  of  exhaustion  from  long-continued  dis- 
charge, his  hands  ernployed  night  and  day  inces- 
santly maintaining  a  fixed  position  of  the  limb,  and 
endeavoring  to  prevent  the  intense  agony  which  oc- 
curs on  the  slightest  movement.  Often  have  I  seen 
the  poor  hip-joint  patient,  when  all  others  have  slept, 
still  wakeful  and  anxiously  engrossed  with  the  one 
and  monotonous  task  of  steadying  the  knee  and  pre- 
venting movement."  This  graphic  description  was 
written  in  advocacy  of  exsection  of  the  hip,  an  opera- 
tion of  heroic  surgery,  described  by  a  fanciful  writer 
as  "  majestic  and  sanguinary,"  Continuing  his  argu- 
ment Mr.  Hancock  proceeds:  "Look  again,  at  this 
patient;  his  position  is  no  longer  one  of  constraint 
and  torture,  it  is  one  of  comparative  comfort  and 
rest.  He  no  longer  suffers  the  extreme  pain,  he  no 
longer  exists  in  dread  of  the  slightest  movement  or 
jar,  his  countenance  loses  its  drawn  and  anxious  ap- 
pearance, the  hectic  subsides  and  we  have  alleviated 
a  very  vast  amount  of  suffering  almost  beyond  the 
power  of  endurance."  Mr.  Hancock's  description 
of  the  change  wrought  by  exsection  applies  with 
exactness  to  that  effected  by  traction  or  fixation. 

Details  of  Application  in  the  Third  Stage. — In  this 
stage  treatment  may  be  promptly  undertaken  regard- 
less of  the  presence  of  abscesses,  sinuses,  or  extreme 
deformity.  The  splint,  being  designed  for  a  normal 
figure,  throws  the  deformity  into  such  marked  relief 


ii6  GROWTH  AND  DEFORMITY. 

that  it  seems  impossible  at  the  first  view  to  proceed. 
With  the  upright  of  the  sphnt  lying  against  the  ex- 
tremely adducted  thigh,  the  pelvic  band  will  neces- 
sarily extend  obliquely  across  the  recumbent  trunk 
in  front  and  behind.  It  will  therefore  be  desirable  to 
begin  by  using  a  perineal  strap  the  length  of  which 
can  be  varied  by  attaching  it  by  buckles  screwed  to 
the  pelvic  band.  The  strap  will  then  be  far  from 
occupying  the  position  directly  under  the  ischiatic 
tuberosity  which  it  would  take  if  the  limbs  were  sym- 
metrically disposed.  It  may  even  be  applied  at  first 
to  the  unaffected  side  of  the  perineum.  Thus,  pro- 
ceeding slowly  and  with  care,  the  instrument  may 
be  so  arranged  as  to  permit  the  employment  of  a 
slight  amount  of  traction  and  counter-traction  by  the 
use  of  the  key.  This  is  at  once  attended  by  a  partial 
and  agreeable  arrest  of  motion,  followed  immediately 
by  commencing  reduction  of  deformity.  In  a  few 
days,  or  in  a  few  hours,  with  freedom  from  pain  and 
with  returning  sleep  and  appetite,  and  with  fresh 
hope  and  confidence  on  the  part  of  the  patient,  the 
case  will  be  more  easily  managed.  In  a  short  time 
symmetry  will  be  found  to  be  so  nearly  restored  that 
the  pelvic  band  will  cross  the  body  transversely  and 
the  splint  can  be  conveniently  worn.  The  buckles 
may  then  be  removed  and  the  long  strap  may  be 
discarded  in  favor  of  a  suitably  short  one  provided 
with  loops  for  buttoning  over  the  ends  of  the  pelvic 


THE  HIP   splint:  117 

band,  which  will  thus  be  brought  down  to  its  proper 
position  below  the  level  of  the  iliac  spinous  processes. 
Flexion  and  adduction  will  have  been  seen  to  dimin- 
ish, the  latter  very  likely  giving  way  to  abduction  to 
such  a  degree  as  to  cause  anxiety  from  extreme  ap- 
parent lengthening.  This  will  in  its  turn  diminish 
with  the  resumption  of  locomotion. 

Weight  and  Pulley. — The  pain  which  attends  this 
difficult  stage  calls  for  treatment  with  the  least  pos- 
sible delay.  While  the  splint  is  being  prepared  a 
weight  and  pulley  may  be  applied.  If  the  pulley  is 
attached  to  the  wall  of  the  room  at  a  considerable 
height,  the  direction  which  the  traction  takes  may  be 
changed,  with  great  convenience  and  without  dis- 
turbing the  patient,  by  rolling  the  cot  toward  or 
away  from  the  wall  or  to  one  side  or  the  other  of 
the  pulley.  When  deformity  has  been  partly  re- 
duced by  the  weight  and  pulley,  treatment  may  be 
continued  by  the  application  of  the  splint.  A  vast 
amount  of  care  and  consideration  may  well  be  ex- 
hibited in  the  management  of  a  case  of  this  kind  un- 
til the  patient  learns  the  use  of  the  key,  when  happi- 
ness and  contentment  take  the  place  of  misery  of  an 
extreme  type.  Many  years  ago  when  mechanical 
treatment  of  this  disease  was  under  consideration  in 
a  children's  ward  at  Bellevue  Hospital,  there  were 
more  hip  cases  than  splints,  and  it  was  necessary  to 
shift  apparatus   from    less    to   more    painful  cases, 


ii8  GROWTH  AND  DEFORMITY. 

which  was  always  done  with  difficulty  and  as  a  cruel 
necessity,  for  the  youngsters  had  learned  to  appreci- 
ate the  comfort  and  convenience  conferred  by  the 
new  treatment. 

The  patient  in  an  advanced  stage,  and  indeed  in 
any  stage,  should  have  a  liberal  and  varied  diet.  He 
will  soon  leave  his  bed  and  join  his  playmates.  He 
becomes  an  office  patient  or,  if  treated  at  a  hospital, 
an  out-patient.  Being  equipped  for  painless  locomo- 
tion, he  is  instructed  in  the  acquisition  of  a  symmet- 
rical gait  characterized  by  normal  rhythm  in  his 
footsteps.  As  he  gathers  strength  and  marches  in 
military  time  it  becomes  evident  that  fixation  is  suffi- 
cient to  save  the  joint  from  pain  and  to  promote  re- 
pair, but  not  so  rigid  as  to  check  restoration  of  shape 
by  the  unconscious  efforts  of  the  patient  to  give  to  the 
limb  an  attitude  convenient  for  locomotion.  There 
will  be  days  when  the  child  will  be  overcome  by  lassi- 
tude, and  nights  of  disturbed  rest.  Such  interrup- 
tions, probably  requiring  medication,  will  diminish 
in  length  and  frequency  with  the  approach  of  re- 
covery. 

The  relaxation  of  the  leather  straps,  which  is  ob- 
served when  the  patient  throws  his  weight  on  the 
splint,  has  the  appearance  of  being  a  failure  in  the  ac- 
tion of  the  apparatus.  It  is  caused  in  various  ways. 
It  may  be  the  result  of  making  the  whole  splint  so 
light  that  it  bends  under  the  weight,  enough  perhaps 


THE  HIP   SPLINT.  119 

to  allow  the  patient's  heel  to  rest  on  the  foot-piece  of 
the  splint.  It  may  also  be  caused  by  wearing  the 
pelvic  band  too  high,  as  shown  in  Fig.  67,  where  the 
curved  line  and  the  dotted  line  represent  the  perineal 
strap  before  and  after  the  weight  of  the  body  falls  on 
it,  causing  a  descent  from  B  io  D  and  a  correspond- 
ing slackening  of  the  leather  straps.  Fig.  68  shows 
a  comparatively  slight  descent  from  B  io  D  effected 


b  D 

Fig.  67.  Fig.  68. 

Figs.  67,  68.— The  Effect  of  a  Long  and  of  a  Short  Strap  (i88i). 

by  lowering  the  band  and  shortening  the  strap.  It 
has  been  suggested  that  in  walking  the  limb  is  sub- 
jected to  alternate  traction  and  relaxation,  and  that 
the  joint  is  thus  exposed  to  a  pumping  process.  It 
may  be  borne  in  mind,  however,  that  the  traction 
made  by  the  use  of  the  key  when  the  patient  is  re- 
cumbent seldom  equals  that  made  by  the  weight  of 
the  limb  when  the  patient  is  erect.  It  is  probable, 
therefore,  that  the  joint  can  be  pumped  only  by  al- 
ternations of  standing  and  recumbency. 

The  Management  of  the  Apparatus  at  Home  may 
be  governed  by  two  rules,  one  of  which  calls  for  per- 


120 


GROWTH  AND  DEFORMITY. 


sistent  separation  of  the  heel  from  the  ground,  re- 
gardless of  the  tension  or  relaxation  of  straps  when 
the  patient  is  up,  while  the 
other  prescribes  that  the  straps 
shall  automatically  become 
tense  when  he  lies  down.  The 
patient,  if  past  the  age  of  in- 
fancy, assumes  control  of  the 
key  himself,  and  he  soon  learns 
that  the  observance  of  the  pre- 
scribed details  secures  conven- 
ience and  freedom  from  pain. 
The  splint  thus  applied  is  worn 
day  and  night,  providing  (i)  for 
general  health  by  exchanging 
the  sick-room  for  out-of-door 
activity,  (2)  for  arrest  of  mo- 
tion in  acute  stages,  (3)  for 
removal  of  weight  from  the 
joint  jn  all  stages,  and  (4)  for 
locomotion  with  the  limb  in 
good  position.  In  a  favorable 
case  a  patient  may  be  said  to 
walk  toward  recovery  cito,  tuto, 
etjitcunde. 

Traction  to  be  Withdrawn.  The  Ischiatic  Crutch. — 
When  it  is  seen  that  the  patient  is  indifferent  to  the 
use  of  the  key  it  is  a  clear  indication  that  he  has 


Fig.  69. — Ischiatic  Crutch. 
Seen  also  in  Figs.  63  and 
64  on  p.  Ill  (1S87). 


THE  ISC  HI  A  TIC  CRUTCH.  121 

passed  out  of  the  acute  stage  in  which  traction  was 
necessary  and  that  the  joint  is  tolerating  motion  and 
disturbance.  The  plasters  may,  however,  remain  on 
the  limb  and  the  splint  may  still  be  worn  at  night  for 
a  few  weeks  or  until  continued  neglect  of  the  use  of 
the  key  makes  it  evident  that  traction, 
agreeable  at  first  on  account  of  its  ano- 
dyne quality,  has  ceased  to  be  desirable 
and  useful  and  is  not  likely  to  be  again 
required.  The  leather  straps  and  the 
plasters  to  which  they  buckle  may  then 
be  removed  and  the  apparatus  may  be 

^^.  -^  Fig.  70.— Splint 

laid  aside  at  night.  It  is  then  useful  shod  with 
only  as  a  protective  splint  and  in  due  ^°'^  Leather 
time  it  may  be  replaced  by  a  simpler  in- 
strument capable  of  being  lengthened  as  the  patient 
grows  by  the  overlapping  parts  seen  in  Fig.  69.  A 
joint  is  sometimes  introduced  in  this  splint  at  the 
level  of  the  knee.  A  release  provides  for  flexion  at 
will  and  firm  extension  is  made  automatically.  With 
the  adhesive  plasters  and  rack  and  pinion  discarded, 
the  upright  may  be  shod  with  sole  leather,  in  the 
manner  seen  in  Fig.  70,  or  with  any  of  the  ordinary 
forms  of  crutch  tip,  one  of  which  is  seen  in  Figs.  64 
and  69.  It  is  then  practically  a  crutch,  weighing 
from  one  pound  and  eight  ounces  to  three  pounds 
and  eight  ounces.  In  other  respects  the  instrument 
is  unchanged  in  its  application  and  adjustment.     It 


122  GROWTH  AND  DEFORMITY. 

is  worn  only  when  the  patient  is  out  of  bed,  as  in 
disease  of  the  knee  or  ankle,  or  in  any  chronic  ail- 
ment in  which  one  limb  requires  protection  from  the 
weight  of  the  body. 

Comparative  Importance  of  Traction  and  Protection. 
—  It  is  an  interesting  question  whether  traction  or 
protection  is  the  more  important  feature  of  mechan- 
ical treatment.  If  the  morbid  foci  were  recognizable 
at  their  very  beginning,  protection,  by  converting  the 
limb  into  a  pendent  member,  might  lead  to  resolu- 
tion with  no  further  trouble  and  traction  might  sel- 
dom be  called  for.  But  the  diagnosis  is  almost  never 
made  until  painful  symptoms  demand  traction,  which 
is  then  extremely  important  as  a  means  of  relieving 
pain  and  promoting  resolution  by  arrest  of  motion. 
It  is  required,  however,  but  a  comparatively  short 
time  in  the  long  duration  of  a  case.  Protection,  on 
the  other  hand,  is  necessary  from  the  beginning  to 
the  end  of  the  treatment.  It  is*  more  indispensable 
than  traction,  since  it  provides  for  locomotion  and 
ultimate  symmetry  and  promotes  resolution  by  ar- 
resting the  most  mischievous  function  of  the  joint, 
weight-bearing. 

While  it  would  be  difficult  to  treat  urgent  cases 
without  resorting  to  fixation,  the  hope  may  be  in- 
dulged that  the  application  of  traction,  or  of  any 
other  form  of  fixation,  will  in  time  become  unneces- 
sary or  unusual  when  improved  methods  of  early 


THE  ISCHIATIC  CRUTCH.  123 

diagnosis  shall  have  made  it  possible  to  induce  reso- 
lution in  the  initial  stage  by  the  timely  enforcement 
of  protection. 

The  significance  of  the  Weight  of  the  Body  as  a 
Factor  in  joint  disease  is  established  by  a  review  of 
certain  figures  drawn  from  the  reports  of  two  ortho- 
paedic institutions  for  a  given  year,  in  which  many 
more  patients  were  treated  for  disease  in  the  lower 
than  in  the  upper  extremity.     The  table  follows: 


Lower  Extremity. 

Hip 558 

Knee 207 

Ankle 64 

Total 829 


Upper  Extremity. 

Shoulder  . . . , 7 

Elbow 16 

Wrist 3 

Total. 26 


At  the  first  glance,  it  would  seem  that  joint  dis- 
ease is  caused  by  the  pressure  and  concussion  which 
fall  to  the  lot  of  the  lower  extremities,  but  this  view 
is  not  in  accord  with  the  indications  of  typical  his- 
tories, which  include  tuberculous  deposits  in  the  can- 
cellous tissue,  which  of  course  may  occur  in  an}-  part 
of  the  skeleton.  The  correct  inference  is  that  foci  in 
the  upper  extremity,  where  they  are  exempt  from  vio- 
lence, undergo  resolution  without  symptoms  or  rec- 
ognition. This  agrees  with  the  fact  that  the  dreaded 
tuberculous  process,  wherever  it  appears,  owes  its 
destructive  quality  to  unfavorable  environment,  me- 
chanical and  otherwise,  and  not  to  an  inexorable  dis- 
position of  its  own.     Quiet  resolution  may  hardly  be 


124  GROWTH  AND  DEFORMITY. 

expected  in  the  lower  extremity  which  feels  the  press- 
ure of  the  weight  of  the  body  and  the  violence  attend- 
ing locomotion,  violence  of  great  severity  when  the 
bones  are  called  to  withstand  the  successive  blows 
which  attend  running  and  jumping. 

Disease  of  the  Wrist.,  Elbow.,  and  Shoulder. — When, 
as  sometimes  happens  of  course,  tuberculosis  of  the 
joints  assumes  destructive  activity  in  the  upper  ex- 
tremity it  may  be  owing  to  the  absence  of  desirable 
arrest  of  motion,  and  in  some  cases  perhaps  to  pas- 
sive motion,  or  brisement  force,  prescribed  for  the  pre- 
vention of  ankylosis.  Fixation  may  readily  be  made 
at  the  wrist  by  a  plaster-of-Paris  dressing  or  a  simple 
supporting  and  restraining  splint,  on  which  the  hand 
and  forearm  are  confined  by  strips  of  adhesive  plas- 
ter, leaving  the  digits  free.  Such  an  application  re- 
stored the  right  wrist  of  a  boy  nine  years  old  who 
was  under  treatment  for  purulent  right  hip  disease,  a 
sinus  appearing  on  the  palmar  surface  of  the  wrist  in 
December,  1890,  about  six  months  after  one  devel- 
oped at  the  hip.  There  was  disintegration  of  each 
joint  with  profuse  and  at  times  offensive  discharge. 
The  sinus  at  the  wrist  permanently  closed  in  August, 
1892,  one  year  after  closure  at  the  hip.  In  1904  limi- 
tation of  motion  at  the  wrist  was  found  only  after 
careful  comparison  with  the  other  wrist.  If  ankylosis 
at  the  elbow  is  unavoidable,  it  should  be  at  an  angle 
giving  the  best  ultimate  convenience  in  the  use  of 


THE  ISCHIATIC  CRUTCH.  125 

the  hand.  A  retentive  spUnt  at  this  point  should 
give  exact  control.  But  a  splint  applied  to  control 
motion  between  the  humerus  and  scapula  will  meet 
with  the  difficulty  which  is  present  at  the  hip-joint,  ab- 
sence of  efficient  leverage  above  the  point  of  motion. 
The  ordinary  methods  of  averting  accidental  disturb- 
ance of  this  joint  and  preventing  undue  use  of  the 
arm  seem  to  afford  sufficient  fixation.  Loss  of  mo- 
tion is  concealed  even  more  readily  at  the  shoulder 
than  it  is  at  the  hip,  where  vicarious  mobility,  in  the 
spine  and  the  other  hip-joint,  gives  remarkable  facil- 
ity in  the  use  of  the  limb.  The  scapula  is  so  loosely 
attached  to  the  trunk  that  its  joint  with  the  humerus 
may  be  ankylosed  with  the  retention  of  very  wide 
use  of  the  arm.  In  his  paper  on  "  Quiet  Necrosis" 
Mr.  Paget  wrote  as  follows :  "  The  most  remarkable 
case  was  a  boy  of  whom,  though  he  had  been  care- 
fully brought  up,  it  was  never  known  that  his  left 
shoulder  was  completely  stiff  till  he  went  to  Eton 
and  was  found  defective  in  some  of  the  school  games. 
The  joint  was  immovable,  the  muscles  around  it 
wasted,  but  it  was  free  from  all  signs  of  disease,  and 
I  fully  believe  always  had  been  so;  and,  whatever 
had  been  the  disease,  it  was  now  passed."  The 
same  good  result  follows  intelligent  expectation  in 
cases  of  purulent  disease  of  the  shoulder-joint. 

Methods  of  Protection.— In  joint  diseases  of  the 
lower  extremities  the  ever  ready  recumbent  position 


126  GROWTH  AND  DEFORMITY. 

of  course  gives  perfect  protection  from  the  traumat- 
isms inseparable  from  locomotion.  Protection  is  also 
furnished  by  horseback  and  bicycle  riding,  either  of 
which  ma}^  be  prescribed  or  allowed  in  suitable  cases. 
For  the  very  young  the  tricycle  may  be  substituted 
for  the  more  difficult  machine.  A  more  common 
resort  is  to  a  pair  of  crutches,  the  usefulness  of  which 
may  be  increased  by  the  addition  of  a  high  sole  to 
the  well  foot.  Experiments  are  on  record  in  which 
a  high  sole  was  added  to  the  well  side  and  a  leaden 
sole  was  attached  to  the  shoe  of  the  affected  limb  for 
the  purpose  of  increasing  the  traction  which  is  nat- 
urally made  by  the  weight  of  the  limb  when  the  pa- 
tient is  erect.  Dr.  Norman  Chapman  advocated 
protection  of  the  diseased  hip  by  flexion  of  the  knee 
in  a  silicate  bandage  in  order  to  keep  the  foot  from 
the  ground.  Mr.  Brodie  said:  "The  patient  should 
never  walk  except  with  the  assistance  of  a  crutch,"  a 
precept  that  has  been  little  regarded,  crutches  being 
usually  considered  not  as  a  curative  device  but  rather 
as  aids  to  locomotion,  or  as  insignia  of  the  crippled 
condition.  The  older  surgical  works  contain  cuts  of 
an  ordinary  crutch  with  a  horn,  or  curved  process,  at 
a  suitable  level  for  receiving  the  ischium  or  the  up- 
per part  of  the  femoral  shaft.  An  artificial  limb  often 
receives  weight  in  the  former  region.  Hip  splints 
furnishing  ischiatic  support  were  described  by  Italian 
surgeons,  and  one  carrying  two  perineal  straps  was 


THE  ISCHIATIC  CRUTCH. 


127 


figured  in  a  surgical  work  published  at  Paris  in  1853. 
Dr.  Edmund  Andrews  was  not  unmindful  of 
the  superiority  of  ischiatic  over  axillary  support 
in  cases  of  chronic  disease  of 
the  lower  extremity.  The  instru- 
ment invented  by  him  is  repre- 
sented in  Fig.  71.  Dr.  Prince  de- 
scribed a  brace  to  which  he  gave 
the  name  of  ischiatic  crutch  in 
1866.  An  inexpensive  form  of 
Dr.  Prince's  splint  is  seen  in  Fig. 
72.  The  well-known  "Dow"  of 
Dr.  Taylor  has  a  convenient  joint 
at  the  level  of  the  knee.  Axillary 
supports  are  conspicuous  and  easily 
forgotten  or  wilfully  laid  aside, 
while  the  ischiatic  crutch  cannot 
be  readily  taken  off,  leaves  the 
hands  and  arms  free,  and  is  almost 
invisible  under  the  clothing.  The 
weight  of  the  body  supported  in 
this  way  is  felt,  not  in  the  un- 
stable and  sensitive  axillae,  but  on  a 
solid  and  basilar  part  of  the  skel- 
eton, which  is  accustomed  to  weight  bearing  in  sit- 
ting and  walking.  The  ischiatic  crutch  seen  in 
Fig.  63  has  been  used  with  convenience  as  an  artifi- 
cial limb  in  a  case  in  which  cosmetic  considerations 


Fig.  71, — Dr.  Andrews 
Splint  (i860). 


I2{ 


GROWTH  AND  DEFORMITY. 


were  negligible.  The  ease  with  which  it  could  be 
lengthened  made  it  especially  suitable  for  a  growing 
child.  It  requires  considerable  time  for  a  patient  to 
learn  to  walk  conveniently  with  this  apparatus  and 
for  the  perineum  to  tolerate  the  presence  of  the  seat 
strap.  Otherwise  it  would  probably  be  frequently 
used  in  fractures  and  other 
acute  cases  requiring  arrest  of 
the  function  of  one  limb. 

Ununited  Fracture,  with  its 
tedious  duration,  presents  an 
emergency  in  which  this  instru- 
ment has  been  useful.  This 
trouble  seems  to  come  to  an  end 
when  the  patient,  unwittingly  or 
by  advice,  exposes  the  fragments 
to  irritation  caused  by  the  use  of  the  limb  im- 
perfectly protected  from  the  corporal  weight.  The 
ease  with  which  the  amount  of  irritation  may  be 
varied  by  lengthening  or  shortening  the  splint  sug- 
gests this  as  a  practicable  resort. 

Discontinuing  the  Treatment  of  hip  disease  is  a  mat- 
ter requiring  the  exercise  of  judgment  and  caution. 
It  is  of  course  better  to  continue  treatment  longer 
than  is  necessary  than  to  desert  the  vantage-ground 
of  protection  too  soon.  -  The  patient  has  become  so 
accustomed  to  the  splint,  and  has  had  so  little  incon- 
venience from  its  habitual  use,  that  he  is  usually  in  no 


Fig.  72. — Dr.  Prince's  "  Is 
chiatic  Crutch"  (1866). 


TREATMENT  OF  HIP  DISEASE.  129 

haste  to  part  with  it.  After  a  long  course  of  protec- 
tion, and  when  the  sinuses,  if  any  have  appeared,  have 
been  replaced  by  firm  scars, 'the  patient  may  be  en- 
couraged to  go  without  the  steel  crutch  every  day  for 
a  short  time,  which  may  be  lengthened  under  judi- 
cious advice.  Later  the  splint  may  be  removed  in 
the  house,  and  reapplied  when  the  patient  goes  out. 
Still  later,  he  may  be  out  of  doors  without  the  splint 
for  a  while  each  day,  and  then  without  it  all  day 
once  or  twice  a  week,  and  finally  it  may  be  laid 
aside  entirely.  A  return  to  ischiatic  support  in  wak- 
ing hours  should  at  once  follow  a  recurrence  of 
symptoms.  While  gradual  release  from  treatment  is 
in  progress,  the  patient  should  be  observed  and  ad- 
vised from  time  to  time  until  the  joint  is  well.  In 
exceptional  cases,  due  to  recurrence  of  disease  or  to 
mistaken  judgment,  there  should  be  resumption  of 
treatment  with  as  much  zeal  and  confidence  as  if  the 
affection  were  beginning.  After  recovery,  the  pa- 
tient should  avoid  extreme  exertion,  such  as  moun- 
tain climbing,  tramping  with  a  gun,  and  long  pedes- 
trian tours.  An  example  of  the  bad  effects  of  undue 
physical  effort  is  seen  in  Case  XI.  recorded  on  pages 
152-154.  It  is  a  strange  fact  that  many  young  people 
with  more  or  less  locomotor  disability  feel  impelled 
to  accept  undertakings  involving  extraordinary  en- 
durance and  physical  exertion.  Their  unreasonable 
ambition  in  this  direction  should  be  checked. 


CHAPTER  VI. 

ABSCESSES   OF   HIP   DISEASE. 

In  many  cases  the  course  of  hip  disease  is  diversi- 
fied by  the  appearance  of  sinuses,  some  of  them  the 
result  of  spontaneous  eruption  and  others  estabHshed 
by  operations  on  swellings  or  diseased  bone.  It  is 
not  easy  to  draw  a  line  between  cases  which  have 
and  those  which  do  not  have  abscesses.  Collections 
supposed  to  be  purulent  may  happily  disappear. 
Operations  on  bone  sometimes  leave  sinuses  with  an 
indefinite  flow  in  cases  which  would  have  shown  no 
discharge  if  the  knife  had  been  withheld.  Such  in- 
stances may  or  may  not  be  included  in  a  compiled 
table  of  cases  attended  by  abscesss.  It  is  therefore 
difficult  to  say  what  percentage  of  patients  have  this 
complication.  Is  it  an  abscess  when  the  fluid  is  con- 
fined in  the  cancellous  tissue  or  in  the  cavity  of  the 
joint,  or  only  when  it  gathers  enough  volume  to  re- 
turn fluctuation,  or  only  when  it  appears  on  the  sur- 
face ?  These  questions  would  be  more  significant  if 
abscesses  were  more  important  features  of  joint  dis- 
ease than  they  are. 

When  abscesses  appear  as  tumors,  and  especially 

130 


ABSCESSES   OF  HIP  DISEASE.  131 

when  they  discharge,  they  are  much  dreaded  in  the 
popular  mind,  but  in  practice  the  management  of  the 
affected  bone  in  which  they  rise  claims  chief  atten- 
tion. They  show  caprice  in  their  early  or  late  ap- 
pearance, their  number,  their  location,  and  in  their 
deportment. 

COLD  ABSCESSES. 

Case  VI. — Cold  Abscess. — A  girl  seven  years  old, 
when  first  seen  in  December,  i88i,had  suffered  from 
disease  of  the  right  hip  for  one  year.  Nine  months 
later  a  fluctuating  tumor  appeared  without  interfer- 
ence with  health  and  activity.  In  two  months,  hav- 
ing reached  a  great  size,  it  opened  on  the  anterior 
and  upper  part  of  the  thigh  when  she  was  sweeping 
the  sidewalk  with  a  toy  broom.  There  was  a  torrent 
of  fluid  containing  flakes  of  caseous  matter.  Col- 
lapse of  the  tumor  was  followed  by  a  varying  dis- 
charge for  seven  months,  which  ceased  with  the 
formation  of  a  scar.  Seven  months  later  moisture 
reappeared,  and  for  eighteen  months  there  was  a  suc- 
cession of  small  scabs  followed  by  a  scar  which,  in 
1898,  was  attached  to  the  bone.  This  abscess  was 
attended  by  no  general  disturbance,  and  caused  no 
pain  or  loss  of  blood.  Other  cases  followed  a  similar 
course. 

In  1879  a  girl  of  the  same  age  had  a  large  collec- 
tion of  matter  on  the  inner  side  of  the  thigh  present- 


132  GROWTH  AND  DEFORMITY. 

ing  at  its  summit  a  small  area  of  insensible  skin 
which  she  broke  with  a  pin,  while  playing  in  the  gut- 
ter. Fluid  escaped  in  a  jet  followed  by  collapse  of 
the  tumor  and  the  formation  of  a  scar  five  months 
later,  which  in  1885  was  depressed  and  attached  to 
the  bone. 

A  boy  five  years  old,  in  1883,  presented  a  fluctuat- 
ing tumor  extending  from  the  trochanter  to  one  inch 
above  the  patella,  which  opened  during  sleep.  He 
thought  he  had  wet  the  bed.  The  sinus  alternated 
between  eruption  and  closure  for  five  and  one-half 
years,  leaving  a  scar  which  was  firm  and  bleached  in 
1898.  The  position  of  the  limb  in  this  case  is  de- 
scribed on  page  179. 

Case  VII. — Cold  Abscess. — A  girl  four  years  old, 
when  first  seen  in  October,  1883,  had  suffered  from 
symptoms  of  disease  of  the  left  hip  for  several  weeks. 
The  usual  signs  of  the  disease  were  present  except 
that  measurements  failed  to  reveal  wasting  of  the 
limb,  the  thighs  being  equal  in  circumference.  Fif- 
teen months  later  fluctuation  was  found  by  palpa- 
tion, extending  downward  two  inches  and  a  half  from 
the  trochanter,  and  the  measurements  were  as  fol- 
lows: Left  upper  thigh,  12^  inches;  lower  thigh, 
^Yi  inches;  leg,  8>^  inches.  Right  upper  thigh,  i2>^ 
inches ;  lower  thigh,  9^  inches ;  leg,  8^  inches.  At 
this  stage  the  affected  thigh  often  measures  between 
one  and  two  inches  less  than  the  well  one.     Its  size 


ABSCESSES  OF  HIP  DISEASE.  133 

in  this  case  was  maintained  by  the  presence  of  a  deep 
collection  of  fluid.  Fluctuation  slowly  disappeared 
and  although  the  limb  slightly  increased  in  size  with 
the  growth  of  the  child,  it  failed  to  keep  up  with  the 
well  limb.  At  a  later  date  the  measurements  were : 
Left  upper  thigh,  13^  inches;  lower  thigh,  9)^ 
inches;  leg,  9/^  inches.  Right  upper  thigh,  15^ 
inches;  lower  thigh,  11%  inches;  leg,  9^  inches. 
Treatment  ceased  in  March,  1888.  There  were  no 
other  abscesses.  The  patient  recovered  and  was 
last  seen  in  September,  1890. 

In  a  similar  case  a  girl  three  years  old  presented  in 
•1887  a  fluctuating  tumor  on  the  anterior  and  outer 
side  of  the  thigh  at  the  junction  of  its  middle  and 
upper  thirds.  It  reddened  and  pointed,  and  an  erup- 
tion was  predicted.  The  tumor  decreased,  however^ 
and  was  gone  six  months  after  its  appearance,  leav- 
ing a  dimple,  seen  in  1893,  twenty  months  after  treat- 
ment had  ceased.  The  pit  was  evidently  caused  by 
the  entanglement  of  fasciae  in  deep  scar  tissue.  It 
was  depressed  as  the  child  gained  in  flesh.  Occa- 
sionally a  patient  receives  a  scar  without  the  appear- 
ance of  a  trace  of  moisture  or  fluid.  A  wide  area  of 
skin  covering  a  fluctuating  tumor  becomes  indurated 
and  thick.  At  one  point  it  thickens  more  and  more 
until  a  substantial  and  prominent  scab  forms.  Fluc- 
tuation slowly  disappears  and  a  depressed  scar  is  left 
resembling  that  which  follows  ordinary  spontaneous 


134  GROWTH  AND  DEFORMITY. 

eruption.  In  all  these  cases  it  was  not  difficult  to 
take  an  expectant  attitude,  which  was  justified  by 
the  results.  The  matter  made  a  harmless  exit  or  dis- 
appearance. Such  a  collection  adds  nothing  to  the 
duration  of  the  disease  and  compromises  the  result  in 
no  way.  The  diseased  bone  recovers,  unmindful  of 
the  deportment  of  the  soft  parts.  Unfortunately, 
very  few  of  the  abscesses  of  hip  disease  act  in  this 
way.  They  are  often  attended  by  pain  and  general 
disturbance. 

INFLAMED   ABSCESSES. 

Case  VIII. —  Cold,  followed  by  Inflamed,  Abscess. 
— A  boy  four  years  old,  when  first  seen  in  Novem- 
ber, 1879,  had  suffered  from  disease  of  the  right  hip 
for  one  year.  Fifteen  months  later  a  cold  abscess 
appeared  and  grew  until  it  occupied  the  upper  two- 
thirds  of  the  outer  side  of  the  thigh,  distending  the 
boy's  trousers.  It  decreased  and  could  not  be  found 
twenty-one  months  after  its  appearance.  The  tis- 
sues were  condensed  and  three  months  later,  without 
a  return  of  fluctuation,  a  sinus  opened  on  the  outer 
side  of  the  thigh  with  pain  and  general  reaction. 
Alternations  of  eruption  and  quiescence  were  ob- 
served for  several  years,  but  without  interference 
with  the  patient's  activity,  until  the  case  was  lost  to 
observation. 

Abscesses  were  attended  by  severe  local  and  gen- 


ABSCESSES  OF  HIP  DISEASE. 


135 


eral  symptoms  in  the  case  of  a  boy  seven  years  old. 
The  first  one  was  incised  on  the  inner  side  of  the 
thigh  in  January,  1875,  and  was  followed  by  three 


Fig.  73.  Fig.  74. 

Figs.  73,  74. — Place  and  Order  of  Sinuses  in  Case  XIII.    (p.  158). 

sinuses  on  the  outer  surface  and  in  the  groin.  Their 
places  and  order  of  appearance  are  shown  in  Figs,  jt, 
and  74.     The  swellings  were  hot  and  painful  and  oc- 


Fig.  75.  Fig.  76. 

Figs.  75,  76. — Place  and  Order  of  Sinuses  in  Case  XII.   (p.  154). 

cupied  wide  areas  of  infiltrated  tissue.  When  at 
their  worst  they  caused  distress  and  debility,  with 
hectic,  febrile  temperature,  failure  of  appetite,  dis- 


136  GROWTH  AND  DEFORMITY. 

turbed  sleep,  and  wasting.  At  such  times  the  boy, 
up  and  dressed  daily,  moved  about  with  crutches  and 
a  splint  with  which  he  maintained  comfortable  trac- 
tion. In  the  intervals  he  discarded  crutches  and  was 
out  of  doors.  After  two  years  the  sinuses  perma- 
nently closed  leaving  scars,  which  twenty-four  years 
later  were  found  attached  to  the  bone  (Case  XIII.,  p. 
158).  A  group  of  abscesses  similar  in  character  and 
effect  appeared  in  the  thigh  and  groin  in  the  case  of 
a  girl  three  years  old,  as  seen  in  Figs.  75  and  76. 
They  complicated  the  progress  of  the  disease  from 
March,  1878,  to  September,  1879,  as  is  recorded  in 
Case  XII.  (pp.  154,  157,  and  158). 

Case  IX.^ — Inflamed  Abscesses. — A  girl  seven  years 
old,  when  first  seen  in  January,  1883,  had  suffered 
from  disease  of  the  left  hip  for  three  years.  A  sinus 
following  an  incision  had  been  open  on  the  anterior 
and  upper  part  of  the  thigh  for  five  months.  Six 
months  later  it  closed  with  a  firm  scar.  At  the  end 
of  two  years  and  three  months  it  reopened  and  closed 
again  after  a  few  months.  This  was  repeated  three 
times  between  October,  1885,  and  August,  1895.  On 
each  occasion  the  gathering  was  marked  by  local  dis- 
tress and  febrile  prostration.  Fragments  of  bone 
were  found  in  the  matter.  In  the  intervals  her 
health  and  ability  were  restored  to  such  a  degree  that 
while  under  treatment  she  acquired  a  practical 
knowledge  of  vocal  music  of  which  she  made  sue- 


ABSCESSES   OF  HIP  DISEASE.  137 

cessful  use.  Her  ability  to  walk  without  lameness  is 
described  on  page  160.  In  1904  the  scar  had  been 
bleached  and  attached  to  bone  for  nine  years  and 
was  probably  conclusive. 

TREATMENT. 

The  management  of  a  case  including  inflamed 
abscesses  is  beset  with  difficulties.  A  knee  thus  af- 
fected was  formerly  thought  to  require  amputation. 
The  general  rule  which  advises  the  free  and  early 
incision  of  all  abscesses  is  recalled,  but  its  authority 
is  weakened  by  a  mental  picture  of  the  liquefying 
bone  which  gives  rise  to  the  matter.  The  urgency 
of  the  symptoms  may  seem  to  call  for  an  incision 
which  with  due  preparation  is  considered  in,  any 
event  harmless,  unless  it  meets  the  objection  that  it 
surrenders  the  protection  provided  by  encysting  mem- 
brane and  gives  purulent  matter  access  to  divided 
vessels.  Much  benefit  can  hardly  be  expected  to  fol- 
low the  opening  of  an  abscess  when  it  is  learned  by 
experience  that  the  date  of  the  final  closure  of  the 
sinus  is  not  thus  hastened  or  the  course  of  the  dis- 
ease modified  in  any  other  way,  effects  not  to  be  rea- 
sonably expected  in  view  of  the  facts  that  incision  has 
no  control  over  the  status  of  the  bone  and  that  the 
step  is  taken  very  late  in  the  history  of  the  abscess. 
A  bistoury  skilfully  directed  in  an  early  stage  might 


138  GROWTH  AND  DEFORMITY. 

release  matter  painfully  imprisoned  in  cancellous  tis- 
sue, and  thus  shorten  the  disease  and  conserve  bone ; 
but  when  pus  has  broken  through  the  compact  shell 
and  lies  in  the  cellular  structures,  or  in  the  cavity  of 
the  joint,  events  may  not  be  controlled  by  local  inter- 
ference of  this  kind.  If  the  abscess  is  cold  there  is 
no  painful  tension ;  if  hot,  the  tension  of  infiltrated 
tissues  can  be  relieved  only  by  multiple  incision.  In 
either  case  artificial  closure  is  sought  with  difficulty, 
and  when  found  is  inferior  to  natural  sealing,  and, 
with  the  observance  of  all  due  precaution,  nothing  is 
gained  by  incision  unless  the  purulent  depot  is 
scraped,  and  then  nothing  unless  affected  tissue  of 
all  kinds  is  removed  and  the  foci  extirpated,  which 
implies  in  many  cases  excision  of  the  joint  or  large 
portions  of  bone.  An  operation,  of  either  minor  or 
major  surgery,  does  not  bar  the  necessity  of  mechan- 
ical treatment,  which  applied  to  the  bone  early  or  late 
will  ensure  a  recovery,  with  or  without  an  opera- 
tion, by  the  slow  but  sure  process  of  natural  repair. 
For  many  years  the  suggestion  that  the  abscesses  of 
joint  disease  might  well  be  intelligently  neglected  has 
found  frequent  expression  in  literature.  It  may  in 
due  course  of  time  receive  general  assent. 

The  appearance  of  an  abscess  is  sometimes  useful 
because  it  leads  to  cheerful  acceptance  on  the  part  of 
the  patient  of  the  inconvenience  of  prolonged  treat- 
ment, the  necessity  of  which  is  clear  only  to  the 


ABSCESSES   OF  HIP  DISEASE.  139 

physician,  who  needs  no  such  reminder  of  the  seri- 
ous condition  of  the  bone.  But  when  an  eruption 
occurs,  indifference  is  apt  to  be  replaced  by  undue 
anxiety  concerning  what  is  thought  to  be  the  most 
serious  incident  of  the  case,  but  which  is  really  little 
more  than  a  complication  requiring  the  observance 
of  customary  sanitation.  An  established  sinus  is 
painless  and  resembles  the  natural  openings  lined 
wdth  mucous  membrane,  and  the  region  readily  tol- 
erates disturbance  and  even  violence. 

Significance  of  Abscesses. — It  is  difhcult  to  explain 
the  appearance  or  non-appearance  of  this  complica- 
tion except  by  the  inconsequent  statement  that  caries 
may  be  dry  or  moist.  It  is  probable  that  the  selec- 
tion depends  on  the  diathesis,  or  something  liable  to 
change  in  the  patient's  general  condition,  rather  than 
on  any  local  change  brought  about  by  treatment  or 
otherwise.  Continued  suppuration  has  been  thought 
to  lead  to  visceral  degeneration ;  but  this  relation  has 
not  been  established,  it  being  questionable  which  is 
the  cause  and  which  is  the  effect.  When  there  is  a 
failure  of  general  health  coincident  with  continued 
suppuration  it  is  probable  that  the  former  is  the  cause 
of  the  latter. 

Origin  of  Abscesses  and  Location  of  Sinuses. — 
Many  attempts  have  been  made,  but  without  notable 
success,  to  drain  the  region  of  initial  foci  by  working 
a  tunnel  through  the  neck  of  the  femur  by  way  of 


140  GROWTH  AND  DEFORMITY. 

the  subcutaneous  surface  of  the  great  trochanter.  It 
is  not  easy  to  ascertain  the  starting-point,  or  route, 
of  an  abscess.  Matter  found  in  the  cavity  of  the 
joint  may  be  composed  of  caseous  debris  diluted  with 
products  of  synovitis.  If  collections  occur  without 
communicating  with  the  joint,  the  matter  must  have 
perforated  the  compact  shell  at  a  point  beyond  the 
attachment  of  the  capsule.  Severe  pain  in  the  early 
stage,  unrelieved  by  traction  and  fixation  and  sud- 
denly ceasing,  has  been  thought  to  be  caused  by  mat- 
ter confined  for  a  while  under  tension  in  the  cancel- 
lous tissue  and  to  presage  a  palpable  collection  of 
fluid.  When  the  latter  has  gained  headway  it  takes 
the  shortest  route  to  the  surface  modified  by  gravity 
and  the  lead  of  muscular  and  other  sheaths.  Thirty- 
five  per  cent,  of  sinuses  have  been  observed  on  the 
anterior,  twenty-seven  per  cent,  on  the  outer,  and 
twenty-five  per  cent,  on  the  posterior  surface  of  the 
hip  and  thigh,  and  thirteen  per  cent,  on  the  inner 
surface  of  the  thigh.  They  do  not  often  interfere 
with  the  application  of  the  hip  splint,  which  makes 
distinct  pressure  only  where  the  ischiatic  and  pubic 
bones  rest  on  the  supporting  strap.  The  scars  w^hich 
follow  the  abscesses  of  hip  disease  may  be  attached 
to  the  femoral  shaft,  to  the  great  trochanter,  to  the 
horizontal  ramus  of  the  pubes,to  Poupart's  ligament, 
to  the  sacrum,  and  to  the  crest  and  anterior  and  pos-, 
terior  superior  spines  of  the  ilium.     They  give  a  re- 


ABSCESSES   OF  HIP  DISEASE.  141 

markably  dimpled  or  tufted  appearance,  especially  in 
those  who  are  inclined  to  be  fat. 

When  exanthemata  intervene  in  the  course  of 
purulent  hip  disease  the  affected  area  shares  in  the 
cutaneous  disturbance,  with  intense  redness,  and  a  dif- 
fused swelling  which  gives  to  the  sinuses  the  appear- 
ance of  cloacae,  or  caverns  emitting  copious  thick 
pus.  It  is  a  common  observation  in  cases  of  long- 
continued  discharge  that  the  patient  suffers  loss  of 
appetite,  lassitude,  and  other  febrile  indications  v>'hen 
the  flow  ceases  for  a  time,  and  that  these  symptoms 
disappear  when  the  discharge  recurs.  When  healing 
of  the  bone  shuts  off  the  supply  of  matter  the  part 
assumes  a  saucer-like  depression,  at  the  bottom  of 
which  a  scab  is  followed  by  a  scar  attached  to  deep 
fasciae  or  to  bone.  The  order  in  which  sinuses  close 
is  not  necessarily  that  in  which  they  open.  The  last 
to  close  is  that  leading  from  the  point  or  area  of  bone 
which  is  the  last  to  cicatrize. 


CHAPTER   VII. 

DIAGNOSIS,  PROGNOSIS,  AND  APPRECIATION  OF 
RESULTS  OF  HIP  DISEASE. 

DIAGNOSIS. 

Two  diagnostic  reminders,  important  in  general 
practice,  find  expression  in  these  words :  The  pain  of 
hip  disease  is  in  the  knee  and  the  pain  of  spine  dis- 
ease is  in  the  stomach.  Recurring  Pain  in  the  Knee ^ 
in  the  absence  of  physical  evidence  of  disease  of  this 
joint,  should  call  attention  to  the  condition  of  the 
hip.  But  pain,  except  as  an  alarm,  is  not  an  important 
indication.  It  belongs  to  the  group  of  subjective 
symptoms  which  may  be  almost  entirely  disregarded 
in  making  a  diagnosis  of  an  affection  which  displays 
so  many  signals. 

Inconstant  Lameness. — Among  the  first  signs  is 
lameness,  which  may  disappear,  to  return  after  an 
interval  of  days  or  weeks;  it  is  present  in  the  morn- 
ing when  the  patient  leaves  his  bed  and  wears  off 
after  a  brief  period  of  activity ;  it  breaks  up  the  nat- 
ural rhythm  of  walking,  in  which  equal  time  is  given 
to  the  two  feet,  leaving  the  well  foot  on  the  ground 
longer  than  the  affected  one,  and  leading  the  former 

to  give  a  more  accentuated  stroke  as  it  hastens  to  re- 

142 


DIAGNOSIS   OF  HIP  DISEASE.  143 

lieve  the  latter  from  the  weight  of  the  body.  Akin 
to  lameness  is  the  attitude  at  rest,  in  which  the  pa- 
tient habitually  stands  favoring  the  affected  limb 
which  assumes  marked  Abduction  and  slight  flexion, 
while  the  weight  is  principally  thrown  on  the  well 
limb.  Next  to  lameness  in  the  order  of  obviousness 
is  Muscular  Atrophy,  owing  partly  perhaps  to  reflex 
interference  with  nutrition  and  seen  in  a  flat  natis  as 
the  patient  stands,  and  in  the  description  of  the  gluteal 
fold,  which  is  shorter  and  more  shallow  and  depressed 
than  that  of  the  well  side,  and  in  the  reduced  circum- 
ferences of  the  thigh  and  leg. 

Reflex  Muscular  Action. — Next  in  turn  comes  the 
most  valuable  sign  of  the  early  stage,  interference 
with  passive  motion  by  reflex  muscular  action.  The 
muscles  are  said  to  be  on  guard.  Verneuil  used  the 
expressive  term  vigilance  musculaire  in  a  graphic 
description  of  this  peculiar  action  or  condition  of  the 
muscles  which,  while  common  to  all  diseased  joints, 
is  best  seen  in  the  hip,  because  a  ball-and-socket  joint 
depends  especially  on  its  muscular  system  for  both 
motion  and  stability.  It  is  a  sign  especially  valuable 
when  lameness  is  inconstant,  atrophy  equivocal,  and 
the  pain  referred  to  the  knee.  It  is  also  significant 
in  convalescence.  It  is  found  earliest  in  rotation. 
Let  the  patient  sit  with  the  legs  hanging  over  the 
edge  of  a  table  and  then  impart  a  lateral  pendulum- 
like motion  to  the  foot  and  note  whether  the  arc 


144  GROWTH  AND  DEFORMITY. 

of  motion  is  less  on  the  suspected  side ;  or  when  the 
patient  is  supine  impel  the  limbs,  one  at  a  time,  giv- 
ing them  a  rolling  motion  outward  and  inward.  On 
the  well  side  the  outer  and  inner  borders  of  the  foot 
will  strike  the  table,  or  nearly  so,  while  on  the  affected 
side  rotation  will  be  limited.  The  patient  may  be  in- 
duced to  apply  a  test  for  limited  passive  flexion  by 
grasping  the  shin  and  kissing  the  knee.  On  the  sus- 
pected side  he  may  not  be  able  to  bring  the  knee  to 
the  mouth.  These  tests  should  be  made  with  delib- 
eration and  gentleness,  the  object  being  to  detect 
very  slight  differences  in  muscular  action,  or  even  to 
recognize  reluctance  of  the  muscles  to  relax  in  cer- 
tain directions,  although  they  mxay  not  yet  by  their 
tonic  action  prevent  wide  motion.  Aside  from  this 
reflex  interference  with  passive  motion,  it  is  inform- 
ing to  note  the  deportment  of  the  adductors  of  the 
thigh  under  palpation.  When  passive  motion  is  at- 
tempted they  may  exhibit  a  momentary  spasm  or  else 
maintain  a  tonic  contraction  until  the  limb  is  re- 
leased, when  they  recover  relaxation ;  or  the  abdomi- 
nal muscles,  as  well  as  the  adductors,  may  show  a  sin- 
gle reflex  spasm  at  the  beginning  of  passive  motion  in 
any  direction.  These  muscular  indications  should  be 
sought  in  both  limbs  for  the  sake  of  comparison.  To 
examine  both  sides  is  a  rule  of  general  application 
which  it  is  never  safe  to  neglect.  A  young  physi- 
cian, after  a  great  variety  of  advice  sought  relief  from 


DIAGNOSIS  OF  HIP  DISEASE.  145 

disability  caused  by  what  was  believed  to  be  a  badly 
united  fracture  of  the  fibula.  The  supposed  faulty 
callus  was  the  prominent  triangular  subcutaneous 
area  at  the  lower  part  of  the  bone.  When  a  similar 
prominence  was  found  in  the  other  leg  the  imagined 
symptoms  and  the  patient's  apprehensions  disap- 
peared. 

A  Useful  Diagnostic  Sign  has  been  described  by  Dr. 
Steele  as  a  "  brawny  thickening  about  the  joint  in 
front  of  the  capsule,  or  behind  the  trochanter."  In 
the  vicinity  of  inflamed  bone  a  condensation  of  the 
soft  parts  may  be  found,  not  visible,  but  recognized 
by  palpation  or  pinching,  and  then  not  clearly  dis- 
cerned except  by  comparison  of  the  two  sides.  A 
smaller  pinch  of  skin  and  underlying  tissue  can  be 
made  on  the  well  than  on  the  affected  side.  None 
of  the  usual  diagnostic  signs  may  be  deemed  conclu- 
sive by  itself.  They  are  to  be  considered  in  com- 
bination and  with  due  regard  to  other  conditions 
which  produce  similar  phenomena.  They  may  be- 
tray hip  disease  in  a  patient  as  yet  free  from  pain 
and  lameness. 

Unmistakable  Signs. — In  a  later  stage,  and  when 
the  disease  is  established,  these  minor  points  may  be 
neglected  because  overshadowed  by  these  three  un- 
mistakable and  easily  read  signs:  (i)  constant  lame- 
ness;   (2)  marked   disparity  in  circumferences,  due 

not  only  to  disuse  of  one  side,  but  also  to  overuse  of 
10 


146  GROWTH  AND  DEFORMITY. 

the  other;  and,  (3)  absence,  or  almost  complete  ab- 
sence, of  motion  in  the  joint.  A  combination  of 
these  salient  features  makes  a  picture  of  hip  disease 
which  is  not  easily  mistaken.  In  regard  to  the  first 
and  the  second  there  is  little  to  be  said,  but  the  ab- 
sence of  motion  may  escape  detection,  movements 
in  the  joint  itself  being  so  closely  imitated  by  vicari- 
ous mobility  of  the  lumbar  vertebrae  and  of  the  other 
hip.  The  absence  of  motion,  or  the  amount  of  mo- 
tion if  some  be  present,  may  be  recognized  by  notic- 
ing the  deportment  of  the  pelvis  when  attempts  at 
passive  motion  are  made. 

To  Discover  Lateral  Motion,  the  patient  lying  con- 
veniently on  a  table  which  is  set  parallel  with  the 
wall  of  the  room,  give  the  limb  passive  abduction  and 
adduction  until  the  iliac  spinous  processes  are  square. 
If  passive  motion  thereafter  disturbs  the  direction  of 
the  line  connecting  the  iliac  spines  there  is  no  motion 
in  the  joint.  If  there  be  some  motion  in  abduction  or 
adduction,  there  will  at  first  be  no  disturbance  of  the 
iliac  spines  and  the  extent  of  motion  will  be  indicated 
by  observing  the  point  in  the  arc  of  abduction  or  ad- 
duction at  which  the  iliac  spines  are  disturbed. 

To  Discover  Antero-posterior  Motion,  raise  the  limb 
until  the  lumbar  spinous  processes  rest  on  the  table. 
If  passive  flexion  or  extension  of  the  elevated  limb 
disturbs  the  spinous  processes  there  is  no  motion  in 
the  joint.     If  there  be  some  motion  there  will  be  at 


DIAGNOSIS   OF  HIP  DISEASE.  147 

first  no  disturbance  of  the  spinous  processes  and  its  ex- 
tent will  be  indicated  by  observing  the  point  in  the  arc 
of  flexion  or  extension  at  which  disturbance  occurs. 

Structural  Shortening. — While  apparent  shortening, 
caused  by  fixation  or  ankylosis  in  a  bad  position,  is 
an  almost  conclusive  sign  of  hip  disease,  structural 
shortening  has  but  little  diagnostic  significance.  It 
occurs  in  acute  epiphysitis,  which  is  a  furious  idio- 
pathic, or  non-traumatic,  inflammation,  producing, 
not  fixation,  but  the  relaxation  and  eversion  of  dias- 
tasis, the  preternatural  longitudinal  mobility  of  con- 
genital dislocation,  and  to  some  extent  the  disability 
and  atrophy  of  infantile  paralysis.  As  traumatism 
is  not  a  factor  of  inflammatory  joint  disease,  it  is 
probable  that  a  so-called  diastasis  with  suppuration 
is  usually  an  instance  of  acute  epiphysitis.  A  differ- 
ential diagnosis  between  the  results  of  epiphysitis, 
diastasis,  single  congenital  dislocation,  infantile  paral- 
ysis, coxa  vara,  and  hip  disease  is  sometimes  a  mat- 
ter of  difficulty.  As  the  first  is  a  profusely  purulent 
affection,  the  presence  of  a  scar  is  generally  a  con- 
clusive indication.  As  an  exception,  no  scar  was 
found  in  the  patient  whose  shortening  is  seen  in 
Figs.  108  and  109  (p.  181),  but  matter  had  found  exit 
in  great  quantity  by  the  vagina. 

Congenital  Dislocation  of  the  Hip. — This  is  a  rare 
and  painless  deformity,  almost  never  recognized  until 
the  child  begins  to  walk.     It  does  not  interfere  with 


148  GROWTH  AND  DEFORMITY. 

efficient  locomotion  and  has  no  reaction  on  health, 
physical  endurance,  or  longevity.  It  responds  indif- 
ferently to  treatment  of  any  kind.  When  double  it 
produces  an  easily  recognized  "  sailor  "  gait.  When 
single,  lameness  may  be  largely  nullified  by  the  as- 
sumption of  the  equine  position  of  the  foot  and  the 
normal  rhythm  of  locomotion. 

Coxa  Vara. — Many  patients  have  probably  received 
routine  treatment  for  hip  disease  in  whom  reflex 
muscular  signs  were  absent  and  whose  trouble  arose 
from  coxa  vara,  or  bending  of  the  femur,  which  re- 
ceives the  weight  of  the  body  at  a  disadvantage  as  it 
falls  in  a  direction  not  parallel  with,  but  oblique  to, 
the  axis  of  the  neck  of  the  bone.  Whatever  may  be 
the  cause  of  this  weakness  of  the  skeleton,  while  it 
exists  the  relief  of  the  affected  limb  from  weight-bear- 
ing is  desirable.  If  bending  of  the  bone  goes  to  the 
extreme  of  producing  serious  deformity  and  disabil- 
ity, osteotomy  will  be  necessary  and  promises  satis- 
factory results. 

Synovitis  after  typhoid  fever  may  simulate  hip 
disease.  A  recent  convalescent  from  typhoid  pre- 
sented limited  motion  and  a  distended  capsule  of  the 
hip-joint.  Osteitis  was  excluded  by  the  history  and 
the  absence  of  reflex  contraction  and  local  muscular 
wasting.  The  patient  was  warned  against  undue  dis- 
turbance of  the  joint  and  recovered  without  disloca- 
tion or  any  special  treatment. 


PROGNOSIS   OF  HIP  DISEASE.  149 


PROGNOSIS. 

As  hip  disease  is  not  in  the  category  of  affections 
likely  to  prove  fatal,  prognosis  concerns  itself  almost 
entirely  with  the  degree  of  resulting  deformity  and 
disability.  At  the  very  beginning,  prognosis  is 
largely  a  question  of  the  date  of  the  diagnosis.  If 
this  is  made  sufficiently  early,  treatment  may  fortu- 
nately induce  resolution  before  the  destructive  proc- 
ess is  under  way.  The  tuberculous  deposits  may  be 
absorbed  or  harmlessly  desiccated,  and  the  usual  de- 
formity and  functional  impairment  may  be  entirely 
prevented.  These  effects  seem  to  have  followed 
early  diagnosis  and  treatment  in  the  following  in- 
stance : 

Case  X. — Incipient  Hip  Disease. — A  girl  seven 
years  old  and  apparently  in  perfect  general  health 
had  symptoms  for  twelve  weeks  which  led  Dr.  Ross, 
her  physician,  to  a  diagnosis  of  disease  of  the  left  hip. 
The  history  included  night  cries  following  days  of 
unusual  exercise,  inconstant  pain  in  the  knee,  and 
lameness  with  long  intervals  in  which  the  child's  gait 
was  normal.  Rheumatism  was  excluded.  The  fol- 
lowing signs  were  seen  on  October  25th,  1900:  Ful- 
ness of  the  groin,  flattening  of  the  natis,  a  shallow 
gluteal  fold,  atrophy  measuring  one-half  of  an  inch  and 
one-quarter  of  an  inch  in  the  thigh  and  leg,  and  limi- 


150  GROWTH  AND  DEFORMITY. 

tation  of  motion  by  reflex  muscular  action  when  the 
extremes  of  passive  motion  were  approached.  On 
November  15th,  1900,  an  ischiatic  crutch  was  appHed 
for  the  protection  of  the  limb,  with  a  high  sole  on  the 
well  foot,  and  on  the  following  day  the  patient  was 
presented  to  the  Orthopaedic  Section  of  the  New  York 
i^cademyof  Medicine.  The  splint  allowed  the  an- 
terior part  of  the  foot  to  reach  the  ground.  The  toe 
could  have  been  kept  clear  by  increasing  the  thick- 
ness of  the  high  sole  and  lengthening  the  splint. 
This  would  have  increased  the  inconvenience  of  the 
application  and  was  unnecessary  in  view  of  the  fact 
that  pressure  transmitted  from  the  toe  by  way  of  the 
ankle-joint  and  the  resistant  muscles  controlling  the 
tendo  Achillis  was  insignificant  when  compared  with 
concussion  passing  directly  through  a  bony  column 
from  the  child's  heel  to  the  hip.  Traction  was  post- 
poned because  it  was  hoped  that  reflex  muscular  ac- 
tion would  cease  when  inflammation  was  subdued  by 
arrest  of  weight-bearing.  If  pain  had  required  atten- 
tion, fixation  would  have  been  enforced  by  the  addi- 
tion of  traction.  The  recumbent  position  would  have 
more  thoroughly  protected  the  joint,  but  the  steel 
crutch  was  sufficient,  as  it  practically  put  the  limb 
to  bed,  while  the  child  was  up  and  going  to  school. 
The  object  of  treatment  was  to  promote  the  resolu- 
tion of  subacute  inflammation  by  relieving  the  limb 
from  the  duty  of  weight-bearing   and    the  labor  of 


INCIPIENT  HIP  DISEASE.  151 

locomotion,  with  the  hope  that  absorption-  or  harm- 
less incarceration  would  take  place  in  a  year  or  two 
years.  Treatment  continued  for  one  year,  and  when 
the  patient  was  again  presented  to  the  Section  on 
December  20th,  1901,  the  only  indications  of  previous 
trouble  were  shortening  of  three-eighths  of  an  inch, 
and  a  want  of  symmetry  not  exceeding  one-fourth  of 
an  inch  in  the  circumferences  of  the  thigh  and  leg. 
A  favorable  artificial  environment  had  encouraged 
natural  resistance  to  disease  and  extinguished  the 
foci  which  otherwise  would  have  broken  into  flame. 
When  examined  in  September,  1904,  the  child  was 
in  excellent  health  and  free  from  the  signs  and  symp- 
toms of  any  joint  disease. 

Reports  of  similar  results  following  early  diagnosis 
would  be  more  common,  if  there  were  less  reluctance 
to  pronounce  so  serious  a  decision  on  an  active  and 
apparently  well  child.  A  more  common  history  in- 
cludes a  record  of  rheumatic  pain,  and  time  passed 
in  waiting  for  an  outbreak  of  startling  signs.  For  a 
long  time  pain  was  thought  to  be  an  essential  feature 
of  early  hip  disease.  This  view  was  held  by  an  old- 
fashioned  physician  who  said  that  he  had  pounded  a 
patient's  heel  at  every  visit  until  his  efforts  elicited  ex- 
pressions of  pain.  It  is  related  that,  many  years  ago, 
a  boy  returning  from  a  clinic  explained  that  he  had  not 
cried  so  much  as  on  previous  occasions  because  he 
Jiad  given  to  the  professors  the  other  leg  to  examine. 


152 


GROWTH  AND  DEFORMITY. 


As  an  early  diagnosis  and  complete  recovery  are 
not  often  recorded,  prognosis  as  a  rule  deals  with  the 
question  of  how  badly  the  patient  will  be  crippled. 


Fig.  77.  Fig.  7b. 

Figs.  77,   7S.— Case  XI.   Third  Stage,  Six   Months  After  Treatment,  Age 

Nine  Years. 

In  many  cases  treatment  is  begun  late,  and  in  others 
it  falls  short  of  full  control  of  the  disease.  Histories 
of  patients  in  the  third  stage  always  present  inter- 
esting features. 

Case  YA.— Third  Stage  of  Hip  Disease. — A  boy 
six  years  old  had  suffered  from  disease  of  the  right 


INCIPIENT  HIP  DISEASE. 


153 


hip  for  nineteen  months.  The  primary  abscess 
opened  spontaneously  in  February,  1877,  on  the  day 
the  patient  was  first  seen.  His  local  symptoms  were 
acute  and  his  general  condition  was  greatly  depressed. 
Exsection  had  been  advised.  Treatment  continued 
two  years  and  five  months.  Six  months  after  it  had 
ceased  photographs  were  taken,  as  seen  in  Figs.  ']'] 
and  78.  Figs.  79  and  80  show  the  place  and  order  of 
the  sinuses.  Locomotor  ability  was  favored  by  the 
position  of  his  limb,  which  was  moderately  flexed,  but 
not  adducted  or  abducted.  His  adult  condition, 
twenty  years  later,  is  seen  in  Figs.  81  and  82.  The 
outlines  of  his  feet  are  shown  in  Fig.  83.  In  the  ab- 
sence of  advice  he  had  for  twelve  years  operated  and 
furnished   the    power  for   a  paper-ruling   machine, 


„/ 


Fig.  79. 
Figs.  79, 


Fig.  80. 
. — Place  and  Order  of  Sinuses  in  Case  XI. 


standing  ten  hours  a  day.  He  also  became  an  expert 
bicyclist  with  a  record  for  distance.  This  restless 
activity  in  work  and  recreation  probably  induced  re- 


154  GROWTH  AND  DEFORMITY. 

current  caries  of  the  shaft  with  added  shortening, 
which  was  largely  neutralized  by  the  equine  position 
of  the  foot  as  seen  in  Figs.  8t  and  82. 


Fig.  81.  Fig.  82. 

Figs.    8i,   82. — Case  XI.   Third   Stage,   Twenty  Years  After  Treatment, 

Age  Twenty-nine  Years. 

Case  XII. —  Third  Stage  of  Hip  Disease. — A  girl 
three  years  old  had  suffered  from  disease  of  the  right 
hip  for  one  year.     Her  mother,  her  grandmother,  and 


THIRD   STAGE   OF  HIP  DISEASE.         155 


Fig.  83.— Case  XI.    Feet  at  Nine  Years  and  Twenty-nine  Years. 


Fig.  84. 


Fig.  85. 


Figs.  84,   85. — Case  Xll.   Third  Stage,  Eight  Months  After  Treatment, 
Age  Five  Years. 


156  GROWTH  AND  DEFORMITY 


Fig.  86. — Case  XII.    Feet  at  Five  Years  and  Twenty- five  Years. 


Fig.  87. 


Fig.  8S. 


Figs.    87,    88.— Case  XIII.   Third  Stage,    Eighteen    Months  After  Treat- 
ment, Age  Twelve  Years. 


THIRD   STAGE   OF  HIP   DISEASE.  157 

several  uncles  and  aunts  had  died  from  pulmonary 
tuberculosis.     Treatment,  begun   in   October,   1876, 


Tic.  Sg.  FiG.  go. 

Figs.  89,  go. — Case  XIII.    Third  Stage,  Twenty  Years  After  Treatment, 
Age  Thirty-two  Years. 

continued  two  years  and  seven  months.  The  result, 
eight  months  after  treatment  of  this  patient  ceased, 
is  seen  in  Figs.  84  and  85.     Her  condition  was  prac- 


158  GROWTH  AND  DEFORMITY. 

tically  the  same  twenty  years  later.  The  place  and 
order  of  the  sinuses  are  shown  in  Figs.  75  and  76  (p. 
135).  The  outlines  of  her  feet  are  shown  in  Fig.  86. 
Case  XIII . —  Third  Stage  0/  Hip  Disease. — A  boy 
seven  years  old  had  suffered  from  disease  of  the  right 
hip  for  four  years.     Treatment,  begun  in  September, 


Fig.  91. — Case  XIII.    Feet  at  Twelve  Years  and  Thirty-two  Years. 

1874,  continued  four  years.  His  condition  eighteen 
months  after  treatment  ceased  is  seen  in  Figs.  87  and 
88.  The  place  and  order  of  the  sinuses  are  seen  in 
Figs.  73  and  74  (p.  135)  and  his  adult  condition  in 
Figs.  89  and  90.  The  outlines  of  his  feet  are  shown 
in  Fig.  91. 

Functional  Results  After  the  Third  Stage. — In  each 
of  these  patients  nothing  was  wanting  to  make  a 
typical  presentation  of  the  severest  form  of  hip  dis- 
ease. The  cases  are  instructive  because  they  show 
that  fairly  good  results  may  follow  treatment  begun 
in  the  third  stage.  They  are  not  cited  to  show  the 
superiority  of  the  instruments  used.     Similar  results 


THIRD   STAGE   OF  HIP  DISEASE.         159 

may  be  obtained  by  the  use  of  any  apparatus, 
whether  it  is  recommended  by  authority  or  devised 
to  meet  the  conditions  of  an  immediate  case,  pro- 
vided it  recognizes  the  necessity  of  fixation,  protec- 
tion, and  convenient  locomotion.  Patients  who  are 
not  seen  until  the  disease  is  far  advanced  cannot  be 
taken  to  represent  typically  the  advantages  of  treat- 
ment. Better  results  are  seen  when  timely  treatment 
anticipates  the  third  stage,  while  the  best  are  re- 
corded only  in  histories  beginning  with  an  exception- 
ally early  diagnosis.  These  cases  have  the  rather 
rare  advantage  of  graphic  comparison  between  re- 
sults immediately  after  and  many  years  after  the  ces- 
sation of  treatment.  They  illustrate  the  contributions 
made  to  symmetry  and  ability  by  growth  and  care- 
fully directed  development.  They  show  that  excel- 
lent functional  restoration  may  be  expected  in  appa- 
rently hopeless  cases.  They  confirm  the  opinion 
that  confident  reliance  may  be  placed  on  intelligent 
expectation  in  the  management  of  the  disease  and  its 
complications.  Although  joint  motion  was  practi- 
cally abolished  in  these  cases  they  call  to  mind  Mr. 
Hilton's  patient,  whom  he  describes  thus:  "She  is 
an  excellent  dancer,  frequently  dancing  for  a  whole 
evening,  and  but  few  persons  know,  when  she  sits 
down,  that  the  right  knee-joint  is  bent  at  right  angles 
with  the  thigh  and  body,  and  tucked  under  the  chair 
to  meet  the  inconvenience  of  her  fixed  hip-joint." 


i6o  GROWTH  AND  DEFORMITY. 

The  patient  whose  abscesses  were  described  in  Case 
IX.  (p.  136)  appears  as  a  soloist  without  defect  in  her 
gait,  although  her  structural  shortening  measures  two 
inches.  Another  patient,  who  formerly  disturbed 
his  neighbors  by  night  cries,  is  a  popular  comedian, 
concealing  his  lameness,  or  making  it  a  grotesque 
feature  at  will,  so  that  friends  do  not  know  whether 
he  is  really  lame  or  not.  Such  cases  are  sufficiently 
common  and  well  known  to  encourage  the  systematic 
instruction  of  patients  in  the  study  and  practice  of 
methods  of  circumventing  deformity  in  the  early 
years  of  life,  when  habits  are  formed  and  growth  is 
an  important  element  in  the  introduction  of  func- 
tional ability. 

MATHEMATICAL  APPRECIATION  OF  RESULTS 
OF  TREATMENT. 

The  note-book  of  an  orthopaedic  clinic  contains  not 
many  cases  of  the  third  stage,  and  fewer  cases  still  in 
which  early  treatment  has  shut  out  all  traces  of  dis- 
ease. When  comparing  results  in  ordinary  cases  the 
degree  of  joint  motion  seems  at  the  first  view  to  be 
of  the  greatest  importance.  When  the  range  of  mo- 
tion is  wide  the  patient  of  course  derives  from  it  con- 
siderable benefit,  especially  when  the  arc  of  antero- 
posterior motion  is  wide  enough  to  favor  sitting  and 
walking. 


RESULTS  OF  HIP  DISEASE.  i6i 

Amount  of  Motion  Less  Important  than  Position  of 
Limb, — A  slight  degree  of  motion,  however,  is  but 
Httle  better  than  immobiHty,  and  as  a  large  propor- 
tion of  patients  have  either  slight  or  practically  no 
motion,  it  is  found  that  the  position  of  the  limb, 
whether  adducted,  flexed,  or  abducted,  is  the  point  of 
chief  interest  and  importance.  If  the  joint  must  be 
almost  or  quite  motionless  the  presence  of  moderate 
flexion  is  desirable  as  it  favors  sitting  and  does  not 
seriously  interfere  with  walking.  Adduction  is  al- 
ways deplorable  because  it  is  equivalent  to  apparent 
shortening  which  is  often  superimposed  on  real  short- 
ening from  loss  of  bone  and  disproportionate  growth. 
On  the  other  hand  abduction  is  always  desirable  be- 
cause it  is  equivalent  to  apparent  lengthening,  which 
may  compensate,  in  part  at  least,  for  real  shortening. 
The  idea  that  absence  of  mobility  from  the  hip-joint 
precludes  locomotion  is  not  found  in  the  mind  of  the 
physician,  who  recognizes  the  fact  that  vicarious  mo- 
tion in  the  other  hip  and  in  the  spine  offers  a  com- 
pensation which  is  attended  by  effective  and  in  favor- 
able cases  almost  normal  locomotion. 

Mensuration  of  Deformity. — Orthopaedic  practice  is 
interesting  especially  because  it  deals  with  what  is 
real  and  tangible.  Physical  demonstration  is  a  part 
of  daily  routine.  Pathological  doctrines  lie  partly  in 
the  domain  of  physics  and  may  be  proved  or  dis- 
proved clinically,  with  mathematical  certainty,  and 
II 


1 62 


GRO  WTH  AND  DEFORMITY.. 


therapeutic  plans  are  worked  out  by  the  application 
of  mechanical  laws.  Subjective  symptoms  give  way 
to  objective  signs,  and  at  the  end  of  treatment  the  re- 


FiG.  92. — Symmetrical 
Position. 


Fig.  93. — Abduction. 


c 

Fig.  94. — Apparent 
Lengthening. 


Fig.  95. — Adduction. 


Fig.  96. — Apparent 
Shortening. 


Figs.  92-96. — Mr.  Marsh's  Drawings,  1877. 


suit  may  be  expressed  in  fractions  of  an  inch  and  de- 
grees of  a  circle.  In  Figs.  92  to  102  the  methods  of 
observing  and  recording  the  phenomena  of  a  case 


RESULTS   OF  HIP  DISEASE. 


163 


of  hip  disease  seem  to  approach  the  details  of  exact 
science.  The  well-known  drawings  of  Mr.  Marsh, 
which  are  reproduced  in  Figs.  92  to  96,  require  no 
explanation.  The  images  seen  in  Figs.  97  and  98 
are  common  dolls  whose  joints  have  been  recon- 
structed in  such  a  manner  as  to  enable  their  limbs  to 


Fig.  97. — Flexion,  30°  (1896). 

be  placed  in  positions  of  abduction,  adduction,  and 
flexion,  the  degrees  of  which  are  indicated  on  a  grad- 
uated scale.  But,  on  account  of  the  rigidity  of  their 
spines,  they  cannot  show  the  factitious  or  "appar- 
ent "  deformities  caused  by  fixation  of  the  hip  in  cer- 
tain positions.  This  is  well  done,  however,  by  the 
pasteboard  silhouettes  seen  in  Figs.  99,  100,  and  loi. 
The  facile  motions  of  the  vertebrae  of  these  shapes 


164 


GROWTH  AND  DEFORMITY. 


enable  them  to  confirm  the  mechanics  of  Mr. 
Marsh's  drawings.  Their  movable  joints  are  lightly 
pressed  shoe  eyelets,  two  of  which  are  posited  on  the 
background  by  screws  at  H  in  the  profile  and  V  in 


w^m 


■f/^ 


Vi 


Fig.  g8. — Abduction,  27.5°  (i 


the  full  figure.  Motion  at  V  in  the  full  figure  allows 
the  pelvis  to  tilt  laterally,  producing  apparent  length- 
ening or  apparent  shortening,  while  motion  at  V,  V 
in  the  profile  enables  the  pelvis  to  tilt  antero-pos- 
teriorly  for  the  production  of  lordosis.  The  thorax 
in  the  profile  is  backed  with  sheet  brass,  to  allay  fric- 
tion between  guide  screws.     The  clip  is  a  common 


RESULTS   OF  HIP  DISEASE. 


165 


scarf   retainer.     The   pieces   before   assembling  are 
seen  in  Fig.  102. 

To  Show  Prodtiction  of  Apparent  Shortening  by 
Adduction. —  In  Fig.  99,  V  in  the  full  figure  is  the 
point  of  motion  which  answers  to  vertebral  mobility 
and  allows  the  pelvis  to  tilt  laterally.  The  clip  ap- 
plied at  A  abolishes  this  motion.  The  limb  may 
then  be  adducted,  as  in  Fig.  100,  by  virtue  of  motion 
at  //,  which  represents  the  position  of  the  hip-joint. 
The  clip  may  then  be  moved  from  A,  where  it  pre- 
vents  vertebral    motion,  to   B,   where  it    abolishes 


Fig.  99. — Symmetrical  Positions  (1896). 

motion  in  the  hip.  Ankylosis  in  the  position  of  ad- 
duction is  thus  imitated.  If,  now,  the  limb  is  moved 
into  parallelism  with  its  fellow  and  the  axis  of  the 
trunk,  as  in  Fig.   loi,  the  pelvis  tilts  and  apparent 


i66 


GROWTH  AND  DEFORMITY. 


shortening  is  the  result.  In  a  similar  way  the  sil- 
houette may  be  made  to  show  how  abduction  pro- 
duces apparent  lengthening. 

To  Show  the  Production  of  Lordosis  by  Flexion. 
— Turning  the  page  ninety  degrees  so  as  to  show  a 
supine  profile,  the  letters  V  and  V  in  Fig.  99  rep- 
resent the  points  of  motion  which  answer  to  vertebral 
mobility  and  allow  the  pelvis  to  tilt  antero-posterior- 


FiG.  100. — Adduction,  20°.     Flexion,  30°. 

ly.  The  clip  applied  at  A  abolishes  this  motion. 
The  limb  may  then  be  flexed,  as  in  Fig.  lOO,  by  vir- 
tue of  motion  at  H,  which  represents  the  position  of 
the  hip-joint.  The  clip  may  then  be  moved  from  A^ 
where  it  prevents  vertebral  motion,  to  B,  where  it 
abolishes  motion  in  the  hip.  Ankylosis  in  the  flexed 
position    is   thus    imitated.     If,   now,   the    limb    is 


RESULTS  OF  HIP  DISEASE. 


167 


Sf'T^y,  '■■^'"        ^wT 


If 


i^i^  5  0  5  loj^-* 


Fig.  ioi. — Apparent  Shortening.     Lordosis. 

brought  down  to  the  table,  as  in  Fig.  loi,  the  pelvis 
tilts  antero-posteriorly  and  lordosis  is  the  result.  It 
is  interesting  to  note,  by  observing  the  relation  of 


Fig.  102. — Parts  of  Fig.  99  Before  Assembling. 


i68  GROWTH  AND  DEFORMITY. 

the  dotted  lines  to  the  figures,  that  height  is  de- 
creased by  flexion  while  it  is  decreased  or  increased 
by  adduction,  according  as  the  patient  stands  on  the 
affected  or  on  the  well  foot. 

To  Measure  Flexion. — While  the  patient  lies  in 
the  supine  position  the  limb  may  be  raised  and  low- 
ered repeatedly  until  a  point  is  found  at  which  the 
lumbar  spinous  processes  press  on  the  table.  One 
arm  of  the  goniometer,  two  forms  of  which  are 
shown  in  Figs.  98  and  100,  may  then  be  held  horizon- 
tally, while  the  other  is  made  parallel  with  the  axis  of 
the  limb.  The  degrees  of  flexion  are  then  seen  on 
the  scale. 

To  Measure  Adduction  and  Abductio7t. — When 
the  point  is  ascertained  at  which  the  anterior  supe- 
rior spinous  processes  are  at  right  angles  with  the 
axis  of  the  trunk,  one  arm  of  the  goniometer  may  be 
held  parallel  with  the  line  of  the  iliac  spines.  For 
convenience,  if  the  narrow  table  is  against  the  wall  of 
the  room,  the  arm  of  the  instrument  may  be  directed 
point  blank  at  the  wall.  It  will  then  be  parallel  with 
the  iliac  spines.  The  other  arm  may  then  be  made 
parallel  with  the  limb  as  nearly  as  may  be.  To  avoid 
errors  which  might  be  caused  by  the  presence  of  a 
knock-knee  or  a  bow-leg  a  line  from  the  middle  of 
Poupart's  ligament  to  the  middle  of  the  heel  may  be 
called  the  axis  of  the  limb.  Degrees  of  adduction  or 
abduction  may  then  be  read  on  the  scale.     The  arc 


RESULTS   OF  HIP  DISEASE.  169 

of  motion  may  also  be  conveniently  noted  and  meas- 
ured. Absolute  accuracy  may  not  be  expected  to 
follow  the  application  of  these  methods,  but  the  re- 
siilts  will  be  better  than  those  obtained  by  the  use  of 
the  eye  alone,  especially  after  the  observer  has  gained 
facility  and  accuracy  by  repeated  use  of  the  measur- 
ing instrument. 

Practical  Shortening  in  the  erect  position  may  be 
estimated  by  placing  the  hands  on  the  iliac  crests 
and  observing  whether  one  is  elevated  above  the 
floor  more  than  the  other.  In  the  supine  position, 
especial  accuracy  may  be  sought  by  using  a  pencil, 
or  ink,  on  the  iliac  spine,  the  middle  of  the  patella, 
and  the  summit  of  the  inner  malleolus  before  apply- 
ing a  measuring  tape.  The  relation  of  the  great  tro- 
chanter to  the  line  connecting  the  iliac  spine  and  the 
ischiatic  tuberosity  will  reveal  the  shortening  due  to 
changes  in  the  acetabulum  and  in  the  femoral  head, 
and  in  the  length  and  direction  of  the  neck  of  the 
femur.  In  taking  the  position  of  the  trochanter  a 
comparison  of  the  two  sides  is  necessary  to  obtain  a 
useful  result. 


CHAPTER  VIII. 

CAUSES  AND  PREVENTION  OF  THE    DEFORMITY 
OF  HIP  DISEASE. 

FACTITIOUS   SHORTENING. 

In  advanced  hip  disease  the  limb  is  unavoidably- 
shortened  by  loss  of  bony  tissue,  and  to  this  cause 
may  be  added  disproportionate  development,  from 
overuse  of  one  limb  and  disuse  of  the  other  at  the 
time  of  growth.  But  this  real  or  structural  shorten- 
ing is  not  the  chief  factor  of  the  lameness.  The  de- 
formity thus  produced  is  not  strikingly  obvious.  A 
new  element,  however,  is  introduced  when  the  limb 
is  fixed,  by  either  muscular  contraction  or  ankylosis, 
in  a  position  which  is  at  variance  with  the  ordinary 
symmetry  of  the  figure.  The  deformity  most  com- 
monly found  in  hip  disease  is  a  combination  of  flex- 
ion and  adduction.  But  even  when  the  limb  is  fixed 
in  a  flexed  and  adducted  position,  deformity  is  not 
apparent  when  the  patient  is  resting;  indeed,  such 
a  position  is  not  in  itself  a  deformity.  This  attitude 
may  be  taken,  and  is  often  taken,  by  the  normal 
body.     But  when   a   limb  thus   situated,  and   fixed 

by  disease,  is  brought  into  parallelism  with  its  fellow 

170 


DEFORMITY  OF  HIP   DISEASE.  171 

and  the  axis  of  the  trunk,  the  absence  of  motion  from 
the  joint  twists  the  pelvis  in  such  a  manner  that  fac- 
titious or  apparent  shortening,  lateral  curvature,  and 
lordosis  come  into  view  and  combine  to  produce 
the  typical  deformity  of  hip  disease.  This  peculiar 
movement  overshadows  the  effect  of  structural 
shortening  and  makes  the  hip-limp,  in  which  one 
side  is  suddenly  distorted  at  each  step.  In  the 
characteristic  lameness  of  hip  disease,  at  the  critical 
moment  when  the  limb  comes  to  a  vertical  position 
to  receive  the  weight  of  the  advancing  body,  the  pel- 
vis rocks  forward  and  laterally  with  a  rude  shock. 
But  if  the  limb  is  fixed  in  a  good  position  the  pelvis 
is  level  when  the  patient  stands ;  and  when  he  walks 
it  rocks  antero-posteriorly  on  the  lumbar  joints  in  a 
moderate  arc  with  resulting  easy  locomotion.  The 
bad  position  is  assumed  early  in  the  disease,  and  ar- 
rest of  motion  or  fixation  in  this  bad  position  is  in- 
itiated by  reflex  contraction  and  maintained  through 
and  after  convalescence  by  fibrous  ankylosis. 

The  Neuro-muscular  Element. — Reflex  contraction 
is  an  early  and  interesting  clinical  feature  most 
thoroughly  elucidated  in  Dr.  Shaffer's  valuable  mon- 
ograph on  "  The  Neuro-muscular  Element  of  Joint 
Disease."  It  did  not  escape  the  eyes  of  John  Hunter, 
who  referred  to  it  when  he  wrote :  "  Stiffness  of  the 
joints  depends  on  involuntary  contraction  of  the 
muscles.     I   think  this  arises  from   sympathy,  or  a 


172  GROWTH  AND  DEFORMITY. 

consciousness  of  the  parts  being  unable  to  answer  to 
the  action  of  the  muscles,  and  it  comes  nearest  to 
human  reason  of  anything  in  the  body."  Dr.  Davis 
said  that  the  muscles  were  "  on  guard." 

The  Movable-immovable  Joint. — A  joint  thus  af- 
fected has  a  peculiar  quality  by  virtue  of  which  it  is 
immovable,  and  at  the  same  time  movable,  a  con- 
dition found  in  some  forms  of  paralysis  in  which  a 
limb  has  been  likened  to  a  piece  of  lead  pipe  which 
firmly  holds  its  shape  and  yet  bends  on  the  applica- 
tion of  suitable  force.  This  quality,  useful  in  the 
reduction  of  deformity,  reveals  its  presence  in  the 
ordinary  events  of  practice.  Recorded  degrees  of 
flexion  or  adduction  are  seen  to  have  increased  or 
decreased  a  few  hours  later  without  any  obvious 
cause,  or  they  are  rapidly  reduced  by  weight  and 
pulley  or  hip  splint,  or  by  the  use  of  Mr.  Thomas' 
splint  in  the  skilful  hands  of  Dr.  Ridlon.  The  limb 
readily  changes  its  position  in  the  successive  stages 
of  the  disease,  abduction  being  followed  by  adduc- 
tion, and  moderate  flexion  becoming  extreme  in  the 
third  stage.  Recalling  these  changes  in  a  limb  stif- 
fened by  hip  disease,  it  may  be  considered  not  far 
out  of  the  way  to  speak  of  the  movable-immovable 
joint.  Fibrous  ankylosis  may  be  quite  far  advanced 
without  forbidding  a  change  for  better  or  for  worse 
in  the  position  of  a  limb  in  response  to  moderate 
force  applied  unwittingly  or  by  design. 


DEFORMITY  OF  HIP  DISEASE.  173 

Ankylosis. — When  ankylosis  is  at  length  thor- 
oughly confirmed  but  little  may  be  done  to  loosen  the 
cicatricial  tissues  and  contractured  ligaments.  The 
acute  stage  has  long  ago  passed  in  which  ankylosis 
might  have  been  averted  or  lessened  by  mitigating 
inflammation.  But  it  would  seem  that  in  the  course 
of  treatment  something  might  be  done  to  bring  the 
limb  into  a  good  position  when  the  joint  is  semi- 
tractable,  and  to  maintain  the  favorable  position 
until  it  shall  have  become  confirmed  by  ankylosis. 
The  ease  with  which  the  position  of  the  limb  changes 
to  suit  the  convenience  and  comfort  of  the  patient 
encourages  confidence  in  the  method  to  be  proposed 
for  the  reduction  of  the  usual  deformity. 

Method  of  Averting  Deformity.— Many  suggestions 
have  been  made  in  explanation  of  the  bad  position 
assumed  by  the  faulty  limb.  It  has  been  thought 
to  be  due  to  effusion  so  abundant  that  the  limb 
takes  the  position  which  accommodates  the  excess 
of  fluid,  to  migration  of  the  acetabulum  and  conse- 
quent change  in  the  lodgment  of  the  head,  to  spasm 
of  the  abductor  muscles  followed  by  their  paralysis, 
giving  advantage  to  the  action  of  the  adductors,  to 
atrophy  and  attrition  of  the  head,  or  to  a  painful 
spot  or  area  on  the  head,  which  had  to  be  revolved 
from  the  depth  of  the  acetabulum  where  it  would 
have  received  too  much  pressure  from  contracting 
muscles.     In  some  cases  and   stages  these   conjee- 


174  GROWTH  AND  DEFORMITY. 

tures  may  answer.  They  take  into  account  the  con- 
dition of  the  joint.  But  the  morbid  anatomy  of 
the  articulation  has  probably,  after  all,  very  little  to 
do  directly  with  the  position  of  the  limb,  which  is 
more  likely  to  be  controlled  by  the  relation  which  the 
limb  bears  to  the  rest  of  the  body.  A  simple  and 
competent  explanation  is  found  in  the  statement  that 
the  limb  obeys  an  unconscious  demand  for  a  position 
which  meets  the  requirements  of  the  patient's  com- 
fort and  convenience.  By  adduction  and  flexion  the 
limb  is  bestowed  quietly  and  comfortably  when  the 
patient  lies  down ;  and  when  he  stands  the  foot  is 
withheld  from  forcible  contact  with  the  ground. 
But  if  these  comfortable  and  convenient  conditions 
were  to  be  secured  in  some  other  way,  if  the  joint 
were  comfortably  restrained  from  painful  movements 
by  a  splint  when  he  lies  down,  and  if  the  apparatus 
were  to  hold  the  limb  above  the  risk  of  injury  when  he 
walks,  the  necessity  of  adduction  and  flexion  would 
be  absent  and  the  limb  would  reach  for  the  ground 
and  resume  its  normal  relation  to  the  rest  of  the 
body.  The  removal  of  the  cause  would  be  followed 
by  a  removal  of  the  effect. 

Difficulty  of  Direct  Mechanical  Reduction. — Indi- 
rect removal  of  deformity  in  the  way  proposed  would 
obviate  the  necessity  of  resorting  to  direct  mechani- 
cal correction.  It  is  noteworthy  that  an  extreme 
deformity   is   more   easily   reducible   by  direct   me- 


DEFORMITY  OF  HIP  DISEASE.  175 

chanical  force  than  a  moderate  one.  A  metallic  rod, 
bent  as  in  Fig.  103,  may  be  readily  straightened 
somewhat  by  manual  traction  and  countertraction,  as 
in  Fig.  104,  and  still  further  by  the  same  forces  me- 


FiG.  103.  Fig.  104. 

Figs.  103,  104. — Straightening  a  Crooked  Rod  by  the  Application  of  Trac- 
tion and  Countertraction. 

chanically  applied,  as  in  Fig.  105.  If  it  is  true  that 
extreme  deformity  is  less  commonly  seen  than  for- 
merly, it  is  probably  because  fewer  patients  fail  to 
receive  traction  in  the  third  stage.  It  is  evident, 
however,  that  the  straighter  the  rod  becomes  the 
harder  it  is  to  make  further  straightening  by  traction. 
It  is  questionable  whether  traction  can  produce 
absolute    straightness.      It    certainly    cannot    over- 


FiG.  105. — Mechanical  Application  of  Traction  and  Countertraction  (1895). 

straighten  the  rod.  But  if  traction  and  countertrac- 
tion are  replaced  by  the  leverage  of  pressure  and 
counterpressure,  as  in  Fig.  io6,  the  rod  may  be  more 
than  straightened  without  much  trouble.    Such  an 


176  GROWTH  AND  DEFORMITY. 

application  is  signally  useful  at  the  knee,  represented 
in  Fig.  1 06,  where  the  leverage  above  and  below  is 
ample.  But  at  the  hip,  which  is  represented  in  Fig. 
107,  leverage  above  the  joint  is  practically  absent  and 
direct  mechanical  reduction  is  therefore  almost  out 
of  the  question.  Control  of  the  position  of  the  limb 
is  thus  seen  to  be  beset  with  difificulties.     Even  if  the 


I 


t 


Fig.  106. — Rod  Representing  Knee       Fig.  107. — Rod  Representing   Hip 
Joint  Easily  Straightened.  Joint  Straightened  with  Difficulty. 

Figs.  106,  107. — Straightening  by  the  Application  of  Pressure  and 
Counterpressure. 

deformity  were  reduced  mechanically,  or  corrected 
by  osteotomy,  it  is  probable  that  the  demands  of 
comfort  and  convenience,  when  the  patient  returned 
from  recumbency  to  the  use  of  his  feet,  would  in- 
cline him  unconsciously  to  seek  comfort  and  con- 
venience by  reinstating  adduction  and  flexion.  The 
effect  would  again  follow  the  cause. 

The  Effect  of  a  Return  to  Normal  Rhythm. — The 
patient  unconsciously  assumes  deformity  in  order 
to  avoid  contact  with  the  ground,  which  he  touches 
with  the  affected  foot  for  a  moment,  withdrawing  it 
promptly  as  if  to  move  it  out  of  the  way  of  the  well 


DEFORMITY  OF  HIP  DISEASE.  177 

limb,  which  hastens  to  do  the  work  of  progression. 
The  two  feet  share  equally  in  the  mischief.  The 
affected  one  is  in  a  hurry  to  leave  the  ground,  and 
the  well  one  is  in  undue  haste  to  strike  the  ground. 
If  a  patient  walking  in  this  pernicious  way  is 
equipped  with  something  that  holds  him  above  the 
reach  of  pain  and  allows  equal  use  of  both  sides,  he 
may  also  unconsciously  moderate  the  haste  of  the 
well  foot  and  allow  the  foot  of  the  affected  side  to 
seek  the  ground  promptly  and  do  its  share  of  the  work. 
From  the  beginning  of  his  trouble  the  patient  has 
favored  the  faulty  limb  and  thus  gained  the  habit  of 
spoiling  the  natural  rhythm  of  walking,  in  which  the 
feet  mark  equal  time.  He  limps  in  order  to  make 
the  well  foot  remain  on  the  ground  longer  than  the 
other  one.  If  an  applied  apparatus  makes  this  un- 
necessary, the  feet  will  be  free  to  move  in  equal  time 
and  the  limb  to  resume  a  normal  position. 

The  argument  for  this  method  of  reducing  the  de- 
formity of  hip  disease  may  be  concisely  stated  in 
these  words.  The  patient  unconsciously  assumes 
a  bad  position  in  order  to  secure  fixation  and  to  es- 
cape painful  contact  with  the  ground.  At  the  same 
time  the  well  limb  usurps  more  than  its  share  of  work 
and  thus  introduces  false  rhythm  in  the  act  of  walk- 
ing. If  a  splint  secures  fixation  and  protection  the 
bad  position  becomes  unnecessary,  and  if  the  patient 

^voluntarily  substitutes  normal  for  abnormal  rhythm 
12 


178  GROWTH  AND  DEFORMITY. 

the  affected  limb  seeks  the  ground  to  do  its  share  of 
work  and  the  bad  position  is  reduced. 

The  suggestion  of  this  mode  of  removing  deform- 
ity had  its  origin  in  the  observation  that  certain  pa- 
tients recovered  in  good  form,  who  for  some  reason 
or  other  had  tried  to  suppress  or  conceal  lameness 
while  wearing  a  splint.  They  seemed  to  have  dis- 
covered for  themselves  that  the  way  to  avoid  the 
appearance  of  lameness  was  to  make  the  two  sides  of 
the  body  move  alike.  A  pretty  girl,  naturally  vain, 
strove  constantly  to  appear  Vv^ell  and  wore  the  splint 
with  but  little  defect  in  her  gait.  She  recovered 
with  no  adduction  and  only  ten  degrees  of  flexion,  al- 
though the  shortening  from  loss  of  bone  measured 
two  inches.     The  following  is  another  instance : 

Case  XIV, —  Unconscious  Correction  of  the  De- 
formity of  Hip  Disease. — A  girl,  five  years  old,  when 
first  seen  in  May,  1880,  had  suffered  from  disease  of 
the  left  hip  for  eighteen  months.  A  weight  and  pul- 
ley and  a  diet  consisting  of  small  portions  of  mutton 
broth  were  replaced  by  a  splint  and  by  a  liberal  menu. 
Through-and-through  drainage  had  been  established 
and  exsection  had  been  advised.  In  due  time  lo- 
comotion was  resumed  and  scars  took  the  place  of 
sinuses  from  which  pieces  of  bone  had  been  expelled. 
She  was  the  only  daughter  and  constant  companion 
of  a  careful  mother.  The  fact  of  disability  was  not 
referred  to  in  conversation  and  its  appearance  was 


DEFORMITY  OF  HIP   DISEASE.  179 

excluded  so  far  as  possible.  The  child  made  good 
use  of  the  affected  limb,  protected  by  the  splint,  and 
walked  without  a  very  noticeable  defect  in  her  gait. 
Health  and  strength  were  entirely  restored  and  re- 
covery was  marked  by  two  inches  of  bony  shorten- 
ing, only  three  degrees  of  adduction  and  practically 
no  flexion,  lameness  being  evident  only  when  she 
was  in  haste  or  moved  carelessly.  The  good  position 
of  the  limb  and  her  general  health  were  maintained 
until  her  fatal  illness,  which  is  recorded  in  Case 
XIX.  (pp.  215,  216). 

On  the  other  hand,  a  boy  five  years  old,  whose 
mother  was  employed  away  from  home  all  day, 
shared  the  sports  of  three  healthy  brothers  and  re- 
covered under  the  same  treatment  and  from  a  milder 
form  of  the  disease  with  twenty  degrees  of  adduction 
and  fifty  degrees  of  flexion,  a  result  which  was  later 
made  the  subject  of  successful  osteotomy.  The  ab- 
scess in  this  case  is  described  on  page  132. 

Another  child,  in  a  large  family,  where  circum- 
stances precluded  ordinary  parental  care,  recovered 
without  an  abscess  and  with  forty  degrees  of  adduc- 
tion. Her  deformity  was  completely  and  easily  re- 
duced in  a  hospital  ward  by  recumbency  and  a 
weight  and  pulley,  but  it  promptly  returned  when 
the  child  went  home  and  resumed  the  hip  splint  with 
which,  disregarding  advice  and  instruction,  she  main- 
tained an  asymmetrical  gait. 


i8o  GROWTH  AND  DEFORMITY. 

It  has  not  been  found  easy  to  reform  the  perni- 
cious gait  acquired  by  a  lame  child.  The  bad  habit 
begins  early  in  the  disease.  It  is  the  first  sign  of 
trouble.  Groups  of  muscles  fall  at  once  into  disuse, 
and  other  groups  are  unduly  developed.  In  this 
state  of  affairs  the  readjustments  of  muscular  ac- 
tivity and  development  called  for  by  a  return  to 
normal  rhythm,  are  not  made  without  some  trouble. 
Such  an  undertaking  will  meet  with  especial  diffi- 
culty in  the  case  of  an  adult.  In  the  tractable  years 
of  early  life,  however,  when  the  muscles  and  joints 
are  increasing  in  size  with  the  growth  of  the  whole 
body,  and  when  new  methods  of  walking  or  march- 
ing are  welcomed  as  diversions,  such  changes  are 
more  readily  made  and  should  not  be  left  to  chance, 
but  intelligently  directed  so  that  they  may  assist 
and  not  impede  successful  locomotion  in  adult  life. 
What  is  more  abhorrent  than  the  thought  that  the 
daily  wonder  of  juvenile  growth  is  adding  to  the 
misfortune  and  helplessness  of  the  crippled  condi- 
tion } 

STRUCTURAL   SHORTENING. 

Real  shortening  is  simple  in  its  causes  when  com- 
pared with  the  shortening  produced  by  fixation  in  a 
bad  position.  It  follows  acute  epiphysitis  of  the  hip 
with  the  result  seen  in  Figs.  io8  and  109.  It  is  seen 
in   single   congenital    dislocation   of    the    hip.     In- 


DEFORMITY  OF  HIP  DISEASE. 


i8i 


stances  are  often  found  after  infantile  paralysis  from 
disuse  of  one  side  and  overuse  of  the  other,  and  it  is 
seen  more  rarely  in  those  cases  of  unilateral  atrophy 
or  congenital  asymmetry  which  are  marked  enough 


Fig.  io8.  Fig.  109. 

Figs.  108,  109.  —  Shortening  Five  Years  After  Acute  Epiphysitis  of  Left 
Hip.  Girl  nine  years  old.  Spinal  curve  reduced  by  factitious  length- 
ening (1877). 

to  cause  disproportion  in  the  length  of  the  lower 
limbs.  Fracture  of  the  femur  of  the  longer  limb  and 
union  with  shortening  has  been  proposed,  but  not 
often  practised,  as  a  method  of  obviating  the  effect 
of  structural  shortening. 


1 82  GROWTH  AND  DEFORMITY. 

Local  Hyperaemia  and  Anaemia.  ^ — Interesting  sug- 
gestions are  derived  from  an  observation,  reported 
by  M.  Broca,  of  the  effect  of  local  hyperaemia  on  the 
rate  of  growth.  In  a  case  of  aneursymal  varix  follow- 
ing wounding  of  the  crural  artery  and  vein  in  a  child 
it  was  found,  fourteen  years  later,  that  limping, 
which  had  been  supposed  to  be  due  to  weakness  of 
the  limb,  was  the  result  of  lengthening  of  more  than 
an  inch.  The  foot  also  was  lengthened.  Such  cases 
are  said  to  be  attended  by  preternatural  growth  of 
hair  on  the  limb.  Hyperaemia,  induced  by  constric- 
tion applied  to  check  the  venous  flow,  is  easily  prac- 
tised and  has  produced  good  results  in  the  cases  of 
joint  disease  reported  by  Dr.  Freiberg.  This,  com- 
bined with  anaemia,  induced  by  rolled  or  laced  ban- 
dages applied  to  the  longer  limb,  might  be  expected 
to  promote  symmetry  in  cases  of  structural  shorten- 
ing. At  the  same  time  the  labor  of  walking  might 
be  redistributed  by  an  ischiatic  crutch  and  a  high 
sole  in  order  to  retard  the  growth  of  the  longer  and 
hasten  that  of  the  shorter  limb.  It  is  stated  by 
Helferich  that  physiological  as  well  as  pathological 
growth  may  be  increased  by  hyperaemia,  and  that  a 
young  growing  bone  may,  under  this  influence,  be- 
come thicker  and  longer.  Reinforced  by  the  activity 
which  possesses  the  development  of  tissue  at  the  time 
of  growth,  such  methods  give  room  for  a  reasonable 
expectation  of  success. 


DEFORMITY  OF  HIP   DISEASE. 


i«3 


To  Circumvent  Actual  Shortening. — The  first  prac- 
tical resort  is  usually  to  a  high-soled  shoe  for  the 
short  limb  and  the  removal  of  part  of  the  sole  from 
the  shoe  of  the  long  limb. 
In  suitable  cases  the  well- 
known  Extension  Shoe  is 
useful.  A  durable  form 
of  this  shoe,  weighing 
two  pounds  and  four 
ounces,  is  seen  in  Fig. 
no.  In  many  cases  if 
the  shortening  is  not  ex- 
treme the  desired  effect 
may  be  found,  and  with 
less  obvious  deformity 
and  inconvenience,  by 
discarding  the  high  sole 
altogether,  withholding 
the  heel  from  the  ground 
and  walking  tiptoe  on  the 
affected  side,  as  is  done 
by  the  patient  seen  in 
Figs.  8i  and  82  (p.  154). 

The  Equine  Position 
of  the  Foot  is  enforced  in 
an  extension  shoe.  It  is  cheerfully  adopted  without  a 
murmur  of  discontent  by  those  who  wear  fashionable 
high  heels,  by  which  the  stature  is  increased  without 


Fig.  1 10. — Extension  Shoe  of 
Wood  and  Steel.  Length  of  limb 
varied  by  adjustment  of  straps 
and  buckles  (1896). 


1 84  GROWTH  AND  DEFORMITY. 

a  total  loss  of  grace.  The  foot  takes  this  position  in 
the  pirouette  of  the  ballet,  and  in  statuary  which  ex- 
presses the  lightness  and  activity  of  the  human  fig- 
ure. As  the  toe  alone  touches  the  ground  when  a 
hip  splint  is  worn,  patients  easily  continue  in  the 
habit  of  walking  in  this  way  when  they  are  advised 
to  do  so  and  to  avoid  a  high  sole ;  and  when  recov- 
ery follows  a  very  prolonged  period  of  treatment, 
a  structurally  shortened  tendo  Achillis  decidedly 
favors  an  equine  position  of  the  foot.  Since  stand- 
ing on  tiptoe  increases  the  stature,  it  is  certainly  rea- 
sonable to  lengthen  a  limb  which  is  unfortunately 
short  by  standing  on  the  toe  of  that  foot.  This  will 
facilitate  efforts  to  practise  and  acquire  a  symmetri- 
cal or  normally  rhythmical  gait. 


LIMPING,  OR   LAMENESS. 

It  is  well  to  bear  in  mind  that  the  lameness  which 
attends  a  short  limb  depends  not  so  much  on  visible 
want  of  symmetry  in  the  lower  extremities  as  on  a 
faulty  carriage  of  the  body.  If  the  two  sides  of  the 
body  in  general  move  alike,  or  symmetrically,  the 
details  of  measurement  are  unimportant.  Lameness 
in  general  may  be  defined  as  asymmetrical  locomo- 
tion.    It  is  said  that  horse  dealers  will  on  occasion 

conceal  the  defect  in  an  animal  lame  in  the  left  fore- 
*■  . 

foot,  for  instance,  by  a  cruel  device  which  makes  the 


LIMPING,    OR   LAMENESS.  185 

horse  lame  in  the  right  foot  also.  A  wedge  is  placed 
between  the  shoe  and  the  well  hoof,  causing  trouble 
on  that  side  which  duplicates  the  disability  and  hides 
lameness  by  balancing  defective  action.  Infantile 
paralysis  often  vitiates  the  gait  by  introducing  tardy 
action  on  one  side,  which  may  be  duplicated  by  an 
effort  on  the  part  of  the  patient  to  make  the  well 
side  imitate  the  affected  one.  Lameness  then  gives 
way  to  the  rolling  gait  of  a  jolly  tar  ashore.  A  well 
person  can  walk  lame  at  will  by  giving  more  time  to 
one  foot  than  to  the  other,  a  matter  of  easy  demon- 
stration if  the  experimenter  will  walk  across  the 
room,  taking  pains  to  let  one  foot  linger  on  the  floor  at 

each  step,  marking  time  as  follows:  1..2 1..2 1..2. 

Conversely,  one  who  is  lame  may  lessen  the  ap- 
pearance of  being  so  by  observing  the  natural 
I.. 2.. I.. 2.. I.. 2.. I. .2  rhythm  of  locomotion  v*^hich  is 
more  effective  in  banishing  a  limp  than  the  equine 
foot  or  extension  shoe. 

The  Rhythm  of  Human  Locomotion  has  perhaps 
not  received  the  attention  to  which  it  is  entitled. 
When  normal  it  is  absolutely  simple  in  comparison 
with  the  varieties  seen  in  quadrupedal  action.  The 
time  is  of  course  equally  divided  between  the  two 
feet.  When  rhythm  is  abnormal,  the  giving  of  more 
time  to  one  foot  than  to  the  other  introduces  lame- 
ness. True  time  may  be  expressed  as  follows : 
I. .2..  I. .2..  I.. 2..  I.. 2..  I.. 2..  I.. 2.. I. .2, 


1 86  GROWTH  AND  DEFORMITY. 

and  false  time  thus: 

I. .2 1. .2 I. .2 1. .2 1. .2 1. .2. 

In  a  child  who  shows  a  limp,  and  no  other  sign,  it  is 
not  easy  to  say  off-hand  which  is  the  affected  limb. 
Attention  will  show  that  the  sound  limb  strikes  a 
quicker  blow  than  the  other,  and  remains  longer  on 
the  ground. 

Symmetrical  Walking.— Aside  from  the  proposed 
method  of  correcting  adduction  and  flexion  in  pa- 
tients who  are  under  treatment,  it  remains  that  the 
habit  of  symmetrical  walking  by  those  who  are  lame 
from  hip  disease,  or  from  any  other  cause,  is  practi- 
cable and  desirable.  A  good  degree  of  excellence 
in  walking  is  attainable  by  those  who  are  badly  dis- 
abled. Instances  of  this  have  already  been  cited, 
and  similar  cases  have  doubtless  been  observed  by 
others.  That  they  are  not  more  common  is  prob- 
ably because  sufficient  attention  has  not  been  given 
to  this  subject  in  practice.  More  time  accorded  to 
the  prevention  of  lameness  by  simple  and  common- 
place methods  would  relieve  many  cripples  of  a  large 
part  of  their  misfortune.  It  is  difficult  to  set  limits 
in  suitable  cases  to  the  success  of  efforts  of  this  kind 
in  the  formative  stages  of  childhood  and  adolescence. 
The  development  of  the  necessary  muscular  fibres 
b}'^  daily  systematic  use  and  the  natural  growth  of 
the  affected  and  related  parts  combine  to  bring  about 
a  result  which  cannot  well  fail  to  be  permanent.     In 


LIMPING,    OR   LAMENESS.  187 

a  child  thus  brought  up  all  the  muscles  and  joints 
and  co-ordinate  acts  of  the  body  will  conform  as 
growth  progresses  with  increasing  facility  and  accu- 
racy with  the  demands  of  improved  locomotion. 

The  Acquirement  of  Correct  Rhythm. — Some  chil- 
dren will  fall  into  the  new  order  of  such  a  curriculum 
with  readiness  and  pleasure,  while  others  are  likely  to 
be  wilful  and  impatient  of  additional  restraints  and 
regulations.  One  or  two  efforts  to  walk  in  good 
time,  or  an  occasional  exercise,  will  be  without  effect. 
Instruction  should  include  the  repetition  of  a  syste- 
matic drill,  a  proceduse  orthopaedic  in  view  of  the 
etymology  of  the  word,  an  educational  process  like 
the  training  of  a  military  recruit.  From  force  of 
habit  the  learner  should  mark  correct  rhythm  in 
walking,  as  a  soldier  carries  out  the  manual  of  arms 
under  fire,  as  a  matter  of  habit  or  second  nature. 
Time  should  be  counted  in  the  promenade,  as  in  a 
music  lesson,  line  upon  line  and  precept  upon  pre- 
cept. In  these  efforts  to  induce  correct  action  atten- 
tion should  be  paid  to  both  of  the  feet,  the  affected 
one  being  taught  to  remain  longer  on  the  ground 
and  the  well  one  not  to  strike  the  ground  too  soon. 
Dancing  exercises  will  not  be  out  of  place.  Per- 
sonal vanity  may  be  stimulated,  and  an  ambition  to 
appear  well.  A  wall  mirror  will  help  an  observant 
child  to  improve  his  gait.  An  impressive  deport- 
ment should  especially  be  encouraged  in  those  who 


i88  GROWTH  AND  DEFORMITY. 

are  disabled.  If  naturally  healthy  children  are  ben- 
efited by  military  drill  and  instruction  in  danc- 
ing, it  is  still  more  important  that  the  afflicted  should 
have  these  educational  advantages.  Treatment  car- 
ried out  in  this  way  may  involve  trouble,  and  the 
time  of  skilled  and  patient  attendants  will  demand 
outlay.  When  convenient,  instruction  might  be 
given  and  exercises  might  be  repeated  in  classes, 
with  music  and  competitive  drills  by  mimic  military 
companies.  The  probable  result  would  be  seen  in 
adults  with  but  moderate  lameness  in  place  of  num- 
bers whose  obvious  defects  entail  a  lasting  disability. 


CHAPTER    IX. 
POTT'S   DISEASE   OF   THE   SPINE. 

The  presence  of  tuberculosis  is  discovered  with 
more  difficulty  in  the  spinal  column  than  in  any 
other  part  of  the  skeleton.  The  bodies  of  the  verte- 
bras lie  behind  barriers  of  bone,  muscle,  and  viscera, 
as  far  removed  from  the  surface  as  possible.  For 
this  reason  the  discovery  of  disease  here  comes  as  an 
unpleasant  surprise.  Disintegration  will  have  made 
great  progress  before  the  contour  of  the  back  shows 
even  so  slight  a  break  as  that  seen  in  Fig.  iii,  which 
indicates  the  loss  of  considerable  substance  from  one 
or  two  of  the  vertebrae.  This  angular  projection  is 
the  first  objective  warning  of  Pott's  disease,  although 
earlier  and  doubtful  signs  are  a  lateral  deviation  and 
a  timid  or  repressed  gait. 

When  the  articulation  of  a  long  bone  is  diseased 
the  effect  of  deranged  motion  is  projected  to  a  dis- 
tance, reaching  the  circumference  of  a  circle  of 
which  the  long  bone  is  the  radius;  but  when  a  short 
and  irregular  bone  is  affected,  the  radius  of  disturb- 
ance is  decidedly  circumscribed.  Lameness  invites 
attention  to  disease  in  the  lower  extremities  long 
before  loss  of  bony  tissue  produces  real  shortening 


igo  GROWTH  AND  DEFORMITY. 

and  deformity.  But  when  the  spine  is  diseased  loco- 
motion is  but  Httle  affected  and  Hmitation  of  motion 
is  not  readily  perceived.  The  result  is  that  diagnosis 
is  usually  necessarily  postponed  until  excavation  of 
the  vertebral  bodies  and  loss  of  large  portions  of 
bone  produce  a  positive  and  unmistakable  deformity. 


Fig.  III. — Normal  Curve  Broken  by  Caries  at  the  Eleventh  Dorsal.  Boy 
four  years  old.  Duration  of  disease  four  months.  (Bellevue  Hospital, 
1877.) 

It  is  disconcerting  to  reflect  that  this  malign  process 
may  be  undermining  the  bones  of  the  spine,  the 
foundation  of  the  edifice,  so  to  speak,  for  so  long  a 
time  undetected  even  under  careful  observation  and 
acute  suspicion.  If  such  foci  of  disease  are  resolv- 
able, when  favorably  situated  in  those  parts  of  the 
skeleton  which  are  exempt  from  weight-bearing,  then 
arrest  of  this  function  of  the  spine  should  without 


DIAGNOSIS  OF  POTTS  DISEASE.        191 

delay  follow  even  slight  suspicion  of  trouble.  Ready- 
acceptance  may  well  be  given  to  published  reports  of 
instances  of  early  and  tentative  treatment  followed 
by  retention  of  normal  shape  and  ability.  In  youth, 
when  the  resistive  and  reparative  powers  share  in  the 
vigor  which  the  whole  body  exhibits  in  its  rapid 
growth  and  development,  it  is  desirable  to  encourage 
the  tissues  to  wall  off  such  an  infection,  and  reason- 
able to  expect  good  results  from  timely  treatment. 

Potfs  Disease  in  the  Aged. — Although  pre-emi- 
nently a  disease  of  childhood,  it  may  not  be  forgot- 
ten that  Pott's  disease  occurs  at  all  ages,  and  is  not 
easily  detected  in  the  later  years  of  life,  when  its 
presence  may  be  obscured  by  spinal  stiffness  and 
deformity  so  commonly  observed  as  the  results  of 
rheumatoid  and  other  affections  which  visit  the  ver- 
tebral column  in  old  age.  The  gait  and  deportment 
of  the  patient,  so  important  in  the  early  diagnosis  of 
this  disease  in  children,  may  be  overlooked  when  the 
patient  is  in  advanced  life,  but  none  of  the  other 
usual  signs  and  symptoms  may  be  safely  neglected. 

DIAGNOSIS. 

Pain  in  the  stomach  is  the  most  important  symp- 
tom. Two  lines  which  should  find  a  place  in  the  vade 
mecum  are :  The  pain  of  spine  disease  is  in  the  stom- 
ach and  the  pain  of  hip  disease  is  in  the  knee.     A  pre- 


192  GROWTH  AND  DEFORMITY. 

scription  for  recurring  colic  should  be  preceded,  or 
presently  followed,  by  a  careful  inquisition  concerning 
the  health  of  the  vertebral  column.  Inspection  may 
reveal  a  projection  in  the  median  line,  which  may  be 
located  by  counting  from  the  seventh  cervical  ver- 
tebra, or  from  the  fifth  lumbar,  which  lies  between 
the  posterior  superior  spinous  processes  of  the  ilia, 
or  one  enumeration  may  be  verified  by  the  other. 
Dr.  Whitman  states  that  the  fourth  lumbar  vertebra, 
on  a  line  with  the  highest  point  of  the  crest  of  the 
ilium,  is  the  most  constant  landmark  from  which  to 
count,  the  umbilicus  being  near  the  same  plane. 
The  rounded  back  of  rickets,  or  that  of  spastic  con- 
traction, should  not  be  mistaken.  In  the  lower  dorsal 
region,  from  the  sixth  to  the  ninth  vertebra,  it  is  also 
well  to  avoid  a  peculiar  source  of  error.  Here  the 
spinous  processes  incline  downward,  overlapping  like 
the  tiles  on  a  roof ;  and  when  a  thin  patient  bends  for- 
ward they  approach  the  horizontal  and  make  a  pro- 
jection leading  to  unnecessary  apprehension,  which 
may  be  avoided  by  noticing  whether  the  projection 
is  angular  or  not.  Lower  down  the  summits  of  the 
spinous  processes  in  a  thin  person  may  be  occupied 
by  distinct  calluses,  caused  by  the  pressure  of  the 
clothing;  but  these  move  with  the  skin. 

The  expression  Angular  Curvature  has  been  criti- 
cised on  the  ground  that  an  angle  and  a  curve  are 
essentially  different.     In  practice,  however,  the  term 


DIAGNOSIS   OF  POTTS  DISEASE. 


193 


is  convenient,  the  normal  long  curve  being  broken 
into  two  short  curves,  meeting  end  to  end  in  an 
angle.  This  point  may  not  project  far,  but  if  it 
marks  the  union  of  two  curves,  in  even  a  slight  de- 
gree, as  in  Fig,  in,  it  means  that  destruction  of 
bone  has  occurred.  An  angu- 
lar curvature  is  usually  an  ab- 
solute demonstration  of  the 
presence  of  Pott's  disease. 

Equilibrium  Preserved  by  Lor- 
dosis.-— When  a  considerable 
angle  is  present  lordosis 
promptly  restores  equilibrium. 
In  Dr.  Homer  Gibney's  patient 
(Fig.  112),  the  deformity  throws 
the  upper  part  of  the  body  for- 
ward, compromising  equilibri- 
um, which  is  safeguarded  by  a 
compensating  curve  below. 
The  same  is  seen  at  A  and  B 
in  Fig.  113.  Lordosis,  scoli- 
osis, and  kyphosis  denote  the 
three  directions  of  spinal  curv- 
ature. Lordosis  is  transient. 
Except  in  opisthotonos  it  does  not  have  the  rigidity 
common  to  the  other  forms  of  deviation,  and  it  dis- 
appears with  recumbency.     It  is  an  adventitious  or 

incidental  curve,  seen  in  double  congenital  disloca- 
13 


Fig.  112. — Equilibrium  Re- 
stored  by  Lordosis.  Age 
seven  years.  Ninth  dor- 
sal. Duration  two  years. 
(H.  Gibney,  igoo.) 


194 


GROWTH  AND  DEFORMirV. 


tion  of  the  hip,  and  also  when  a  weight  is  carried 
in  front,  as  in  gestation.  It  accompanies  the  flexion 
of  hip  disease,  or  that  produced  by  a  shortened  psoas 


Fig.  113. — Equilibrium   Restored  by  Lordosis  and  Horizontal  Vision  by 
Extension  of  the  Head  (1901) . 

muscle  in  Pott's  disease.  It  is  seen  in  the  saddle- 
back of  pseudo-hypertrophic  muscular  paralysis. 
Enforced  lordosis  at  the  lower  part  of  the  spine 
would  probably  counteract  the  effects  of  puerperal 
dislocation  of  the  pelvic  bones,  as  was  pointed  out 
by  Dr.  Goldthwait  at  a  recent  session  of  the  Amer- 
ican Orthopccdic  Association. 

Diagnosis  in  the  Cervical  Region. — It  is  often  diffi- 
cult to  distinguish  between  caries  in  the  middle  and 
upper  cervical  region  and  rheumatic  stiffness  of  the 
posterior  muscles  of  the  neck.  Disturbance  of  the 
head  is  very  positively  resented  in  both  affections, 
and  even  when  the  wry-neck  is  the  result  of  caries 
an  angle  is  not  easily  perceived,  the  cervical  proc- 


DIAGNOSIS  OF  POTTS  DISEASE. 


195 


esses  being  small,  separated  by  narrow  intervals  and 
hidden  by  the  muscular  masses  of  the  superior  fibres 
of  the  trapezius.  In  some  cases  a  point  may  be 
gained  by  looking  for  displacement  forward  of  the 
axis  of  the  head,  which  is  produced  by  the  action 
shown  at  C  and  D  in  Fig.  113.  At  C  the  head  is 
inclined  forward  by  kyphosis  in  the  cervical  region, 


Fig.  114. 


Fig.  115. 


Figs.  114,  115. — Cervical  Disease.  Forward  displacement  of  axis  of  head. 
Age  fifty  years.  Duration  five  years.  Horizontal  vision  restored  by 
extension  of  head.      (New  York  Hospital.) 

when  the  necessity  of  maintaining  horizontal  vision 
induces  extension  of  the  head  and  produces  what 
may  be  called  lordosis  above  the  seat  of  disease. 
The  result  is  a  forward  displacement  of  the  axis  of 


196  GRO  WTH  AND  DEFORMITY. 

the  head,  seen  at  D,  and  also  seen  in  Figs.  114  and 
115.  This  patient,  fifty  years  of  age,  presented  the 
widening  and  prominence  of  the  upper  and  back  part 
of  the  neck,  which  is  admirably  shown  by  a  cut  in 
Dr.  Young's  treatise.  She  had  been  entirely  dis- 
abled for  many  months,  in  which  her  head  had  been 
flexed  and  tilted  to  the  left.  Relief  had  been  sought 
by  manual  support  of  the  head  and  by  the  careful 
arrangement  of  many  pillows  at  night.  The  lower 
part  of  the  spine  and  all  of  the  other  joints  were  nor- 
mally flexible.  When  observed  in  1901,  and  again  in 
1904,  painless  crepitus  was  produced  at  will  by  rota- 
tion to  the  right  with  the  head  flexed  and  supported 
by  the  left  hand.  It  was  always  the  same,  being 
composed  of  three  or  four  closely  connected  sounds. 
Occurring  sometimes  unexpectedly  it  was  alarming 
in  its  distinctness.  It  was  thought  to  be  analogous 
to  the  crepitus  not  uncommon  after  disease  in  other 
joints,  and  could  hardly  have  occurred  after  Pott's 
disease  except  in  the  cervical  region,  where  the  ver- 
tebrae have  considerable  mobility. 

To  make  a  diagnosis  before  the  appearance  of  de- 
formity, several  things  may  be  borne  in  mind.  The 
child  avoids  stamping  with  his  heels  and  puts  more 
weight  on  his  toes  than  is  customary;  or  he  walks 
as  one  stepping  on  a  surface  liable  to  break ;  or  the 
line  made  by  his  head  as  he  moves  across  the  room 
is  straight  and  not  the  undulating  line  traced  by  the 


DIAGNOSIS  OF  POTTS  DISEASE.         197 

rise  and  fall  of  the  figure  in  the  buoyant  gait  which 
belongs  to  childhood.  The  deportment  is  then  to 
be  considered.  He  will  play  quietly  by  himself ;  or, 
easily  tired,  lean  across  his  mother's  lap ;  or,  if  the 
disease  is  at  a  high  level  he  may  support  his  head 
manually  when  sitting  and  even  when  walking.  His 
forehead  may  rest  on  the  edge  of  a  chair,  his  hands 
being  busy  with  toys  on  the  floor.  He  is  disturbed 
by  the  jar  of  a  carriage  or  street  car.  The  progress 
of  a  rough  game  may  be  interrupted  by  a  seizure  of 
gastralgia,  laughter  ending  in  tears.  A  common 
sign  is  a  frequent  or  habitual  grunt  with  expiration. 
By  following  these  lines  of  observation  a  positive 
diagnosis  may  happily  be  made  before  the  unmistak- 
able angle  appears.  In  diagnosis  but  little  attention 
may  be  paid  to  the  general  condition.  Many  cases 
are  encountered  in  which  the  health  is  good  in  every 
stage,  as  shown  by  normal  appetite,  good  digestion, 
and  wholesome  facial  expression  and  color.  While 
these  signs  of  general  well-being  are  persistent  the 
insidious  foe  may  be  in  quiet  pursuit. 

Unexpected  Clinical  Features. — In  two  points  thus 
far  the  unexpected  has  claimed  attention.  The  pain 
is  in  the  stomach  and  not  in  the  back,  and  the  health 
seldom  shows  a  reaction.  Another  surprising  clini- 
cal feature  is  seen  in  the  fact  that,  although  the  back 
is  virtually  broken  in  Pott's  disease,  the  local  disabil- 
ity which  usually  attends  fractures  is  very  rarely  ob- 


198  GROWTH  AND  DEFORMITY 

served.  So  true  is  this  that  in  the  presence  of  spinal 
pain  and  disabihty  the  prompt  conclusion  is  that  the 
affection  is  not  Pott's  disease.  When  these  alarm- 
ing symptoms,  pain  and  disability,  are  combined 
with  a  frank  onset,  it  is  necessary  to  consider  the 
possibility  of  cancerous  disease  involving  the  verte- 
brae. 

Case  XV. — Malignant  Disease  of  VertebrcB. — In 

1884  a  boy,  four  years  and  eight  months  old,  had 
been  noticed  walking  and  stooping  carefully  and 
stiffly.  The  contour  of  the  spine  was  nearly  or  quite 
normal.  Pott's  disease  was  recorded  by  independent 
observers  and  preparations  were  made  for  mechani- 
cal support.  Six  days  after  the  first  examination 
paraplegia  occurred,  and  two  days  later  a  catheter 
was  required,  withdrawing  pus  and  blood  with  the 
urine.  The  bowels  were  regular  and  pain  in  the  back 
was  urgent.  The  abdomen  was  tympanitic.  There 
was  no  cedema  of  the  limbs.  The  temperature  was 
101°  F.  Occasional  slight  convulsions  were  noted. 
Ten  days  later  death  occurred  after  partial  disap- 
pearance of  the  paraplegia.  The  autopsy  revealed 
no  caries,  but  many  tumors  were  found  attached  to 
the  dorsal  vertebrae  and  the  ribs.  The  largest  was 
about  two  and  a  half  inches  in  diameter.  The  neo- 
plasm, had  entered  the  vertebral  foramina. 

Case  XVI. — Malignant  Disease  of  Vei^tebrcs. — In 

1885  a  man,  thirty-five  years  of  age,  had  suffered 


DIAGNOSIS   OF  POTT'S  DISEASE.         199 

much  for  several  months  with  pain  in  the  thighs  from 
supposed  renal  calculus.  There  was  great  loss  of 
flesh.  Painful  disability  was  so  extreme  that  he 
could  with  difficulty  lie  down  or  rise  from  a  couch. 
The  spinal  curves  being  normal,  Pott's  disease  was 
excluded,  a  former  diagnosis  being  reversed.  When 
an  autopsy  was  made  five  months  later,  malignant 
growths  were  found  in  the  lungs  and  on  the  dia- 
phragm and  vertebral  column. 

Case  XVII. — Malignant  Disease  of  Vertebrcs. — 
In  1890  a  brace  was  applied  to  the  spine  of  a  man 
who  was  paraplegic  from  supposed  Pott's  disease, 
following  a  strain  when  helping  to  lift  a  piano.  The 
eighth  dorsal  vertebra  showed  a  slight  angular  promi- 
nence. After  ten  weeks,  in  which  the  history  in- 
cluded faecal  and  urinary  incontinence,  an  explo- 
ratory opening  made  in  the  vertebral  canal,  with  the 
hope  of  relieving  the  paraplegia,  exposed  an  unsus- 
pected sarcoma.  The  patient  lived  a  few  days,  and 
inspection  was  not  carried  further.  The  chief  points 
of  differential  diagnosis,  as  formulated  by  Dr.  Myers, 
are:  Deformity  present  in  Pott's  disease  and  absent 
in  malignant  disease;  and  local  pain  and  disability, 
absent  in  Pott's  and  present  in  malignant  disease. 

Deplorable  Effects  in  the  Dorsal  Region. — The  joints 
of  the  spine  are,  from  their  position  near  the  centre 
of  gravity  and  motion,  peculiarly  exposed  to  me- 
chanical disturbance.     In  this  respect  their  environ- 


200  GROWTH  AND  DEFORMITY. 

ment  is  the  counterpart  of  that  of  the  hip-joint,  which 
was  so  forcibly  described  by  Mr.  Ciiarles  Bell  (see  pp. 
98,  1 01).  For  this  reason  among  others  caries  of  the 
vertebrae  is  a  most  serious  affection.  Very  much, 
however,  depends  on  the  region  involved.  In  the 
dorsal  region,  excepting  malignant  trouble,  it  is  prob- 
ably the  most  serious  affection  that  may  visit  the 
growing  skeleton.  Here  the  disease  is  likely,  if  neg- 
lected, to  extend  for  a  considerable  distance  along 
the  spine,  with  liquefaction  of  large  portions  of  bone 
and  a  portentous  kyphosis,  because  here  the  column 
is  at  its  greatest  mechanical  disadvantage.  The 
effect  of  a  transverse  strain  diminishes  as  the  ends 
of  a  column  are  approached.  In  the  dorsal  and  lum- 
bar regions  rotation  adds  to  mobility  when  the  spine 
bends  laterally,  and  in  the  former  the  movements  of 
respiration  subject  the  diseased  bones  to  habitual 
traumatism.  In  the  cervical  region  the  vertebrae 
have  less  weight  to  carry.  In  the  lumbar  region  the 
vertebral  bodies  by  reason  of  their  size  exhibit  a  firm 
relation  of  mutual  support.  This  natural  support  is 
so  strong  and  the  effect  of  a  lever  so  near  the  end  of 
a  column  is  so  weak  that  mechanical  support  given 
to  the  lumbar  spine  is  not  practically  a  useful  appli- 
cation. For  these  reasons  tuberculosis  of  the  ver- 
tebrae and  its  effects  are  less  to  be  dreaded  in  the 
upper  and  lower  regions  than  in  the  dorsal  region  of 
the  spine,  where  the  intractableness  of  the  affection 


TREATMENT  OF  POTTS  DISEASE.       201 

and  its  serious  results  are  but  too  well  known. 
Here  the  demand  for  painstaking  and  urgent  treat- 
ment is  imperative. 

TREATMENT. 

Whatever  the  difficulties,  authorities  unite  in  the 
opinion  that  nil  desperandum  should  be  the  rule 
when  treating  Pott's  disease.  The  tuberculous  proc- 
ess in  this  as  in  other  parts  of  the  skeleton  may  not 
be  cut  short  by  operative,  or  any  form  of  positive, 
procedure.  The  cessation  of  this  form  of  morbid 
activity  may,  however,  be  confidently  predicted,  and 
a  suitable  mechanical  environment,  reinforced  by  the 
vitality  of  adolescence,  may  be  relied  on  to  hasten 
the  advent  of  the  natural  process  of  repair.  The  un- 
dermined vertebrae  may  be  placed  in  their  best  ex- 
pectant attitude  by  restraining  the  facile  movements 
of  the  column,  by  taking  from  it  the  burden  of  im- 
pending weight,  and  by  averting  the  jar  which  it 
feels  at  every  step  in  walking  and  running. 

Recumbency. — In  the  treatment  of  hip  disease, 
while  the  patient  is  up,  the  limb  is  put  to  bed,  so  to 
speak,  by  ischiatic  support,  an  effective  method  not 
applicable  here.  The  recumbent  position  may  there- 
fore be  prescribed  and  continued  so  long  as  it  is 
practicable  with  due  regard  to  the  patient's  age  and 
general  welfare.     It  is  clear  that  in  this  position  the 


202  GROWTH  AND  DEFORMITY. 

spine  is  free  from  weight-bearing  and  concussion 
and,  to  a  limited  extent,  from  motion.  Recumbency 
in  a  young  patient  may  be  enforced  by  the  use  of 
Dr.  Bradford's  admirable  portable  frame,  made  from 
steel  tubing,  and  arched  by  Dr.  Whitman  at  the  level 
of  the  disease  to  oppose  deformity.  On  this  the 
child  enjoys  freedom  from  disturbance  which  might 
excite  the  morbid  process  or  delay  its  resolution. 
The  environment  thus  secured  is  eminently  hos- 
pitable to  the  approach  of  repair  and  recovery.  The 
width  of  the  frame  is  from  six  to  nine  inches,  the 
width  of  the  body,  not  of  the  shoulders.  The  under- 
shirt is  cut  up  the  back  and  buttoned  only  behind 
the  neck,  the  rest  of  the  clothes,  or  blankets,  going 
around  the  frame.  The  patients  wheel  themselves 
on  suitable  wagons  in  the  house  and  are  carried  into 
the  open  air,  perfectly  happy  and  contented  for  a 
year  or  more.  Dr.  Napier,  describing  the  arrange- 
ment, writes  that  in  this  way  he  treats  children  up  to 
nine  or  ten  years  of  age,  and  adds  that  he  thinks  no 
other  method  its  equal. 

Mechanical  Support. — But  when  the  patient  gains 
in  weight  and  size,  and  the  demands  of  education  in 
various  ways  become  imperative,  it  will  be  desirable 
to  resort  to  some  method  not  incompatible  with 
walking.  It  is  evidently  not  an  easy  undertaking  to 
arrest  motion  in  the  many-jointed  spine.  In  white 
swelling  of  the  knee  a  simple  retaining  brace  fixes 


TREATMENT  OF  POTT'S  DISEASE.       203 

the  joint  with  a  leverage  which  is  wanting  in  a  simi- 
lar application  made  to  the  spine.  In  the  hip  fixa- 
tion is  successfully  and  with  advantage  developed  by 
traction,  and  this  may  be  applied  to  the  uppermost 
region  of  the  spine  when  the  patient  is  recumbent. 
But  in  the  erect  position  traction  is  not  conspicuous- 
ly successful  as  a  fixative.  Suspension  of  the  head 
by  the  jury  mast,  applied  to  avert  impending  weight 
and  straighten  the  column,  is  attended  by  an  uncer- 
tain degree  of  fixation,  theoretical  rather  than  prac- 
tical, and  not  to  be  compared  with  the  comfortable 
fixation  which  is  developed  by  traction  of  the  leg.  It 
may  therefore  be  inferred  that  fixation  of  the  erect 
spine  is  to  be  sought  only  by  applying  a  retentive 
lever  designed  for  making  pressure  at  the  level  of  the 
projection  and  counterpressure  above  and  below. 
An  obvious  effect  of  this  application  is  a  redistribu- 
tion of  intervertebral  pressure.  As  the  column  in- 
clines forward,  making  a  salient  posterior  angle,  there 
is  a  critical  increase  of  pressure  from  impending 
weight  on  the  anterior  rim  of  the  affected  vertebra. 
A  brace  at  once  takes  off  some  of  this  traumatism 
and  puts  it  on  the  posterior  and  sound  part  of  the 
bone.  It  is  a  faint  imitation  of  the  admirable  me- 
chanics of  the  hip  splint  which  transfers  weight  from 
the  affected  to  the  sound  limb.  Injurious  pressure 
is  thus  mitigated  and  a  barrier  is  thrown  up  at  the 
same  time  against  increasing  deformity. 


204  GROWTH  AND  DEFORMITY. 

If  such  an  apparatus,  efficient  in  theory,  proves  not 
to  be  mechanically  perfect  in  practice,  it  will  still  be 
found  to  be  useful.  The  presence  of  a  succession  of 
jointed  short  bones  instead  of  a  single  long  bone 
above  and  below  the  diseased  point  introduces  an 
element  of  inefficiency  in  the  action  of  this  otherwise 
admirable  apparatus.  The  force  applied  to  oppose 
deformity  is  unfortunately  largely  absorbed  in  bend- 
ing backward  sound  portions  of  the  column  above 
and  below  the  point  of  disease.  And  yet  a  useful 
degree  of  fixation  may  be  made,  enough  to  check 
gastralgia,  to  promote  comfortable  activity  on  the 
part  of  the  patient,  and  to  secure  a  diminution  of 
ultimate  deformity.  It  is  important  and  interesting 
to  observe  that  in  this  way  an  incidental  improve- 
ment is  secured  in  the  patient's  figure.  As  the  spine 
yields  to  pressure,  lordosis  is  formed  above  and  be- 
low the  projection,  and  the  trunk  acquires  a  general 
straightening  and  a  fulness  of  the  chest,  which  mod- 
ify the  typical  deformity  produced  by  this  affection. 

Incidental  Improvement  of  the  Figure.— Long-con- 
tinued wearing  of  such  a  brace,  even  after  consolida- 
tion is  assured,  changes  the  figure  by  lessening  the 
roundness  which  is  usually  seen  behind  the  shoulders 
and  by  giving  prominence  to  the  chest,  which  is  a 
decided  improvement.  The  torso  of  a  young  pa- 
tient may  be  seen  to  double  its  size  with  the  child's 
growth.     The  adolescent  years  in  such  a  case  may 


TREATMENT  OF  POTT'S  DISEASE.      205 

therefore  well  be  occupied  by  mechanical  support  of 
a  positively  antero-posterior  kind,  which  will  give 
ever  increasing  benefit  from  its  coincidence  with 
the  period  of  growth  and  development.  Indeed,  if 
effective,  the  brace  will  be  so  comfortable  and  help- 
ful that  the  patient  will  prefer  to  continue  its  use 
long  after  removal  has  been  prescribed.  It  is  only 
in  the  dorsal  region  that  the  brace  can  thus  exert  an 
influence  on  the  figure.  In  other  regions  treatment 
may  be  discontinued  when  consolidation  is  com- 
pleted. 

Natural  Reaction  and  Consolidation. — It  is  not  to  be 
hoped  that  mechanical  treatment  will  at  once  induce 
consolidation.  This  will  wait  for  the  appearance  in 
due  time  of  natural  reaction,  but  it  is  not  difficult 
to  believe  that  nature  will  more  promptly  intervene 
when  distress  and  weakness  and  apprehension  are 
replaced  by  a  feeling  of  strength,  which  finds  expres- 
sion in  the  face  and  attitude.  If  it  were  only  pos- 
sible successfully  to  apply  positive  means  for  the 
arrest  of  the  tuberculous  process,  the  damaged  ver- 
tebrae might  be  treated  at  once  as  if  they  had  sus- 
tained a  simple  fracture.  Instant  provision  should 
then  be  made  for  consolidation  or  union.  Coap- 
tation of  the  fragments  and  their  retention  in  posi- 
tion should  then  be  sought  just  as  they  are  after  a 
fracture  of  any  part  of  the  skeleton.  If  tuberculous 
action   were   really   absent   it   might   be   well   even 


206  GROWTH  AND  DEFORMITY. 

to  adopt  the  periodically  rejuvenated  proposition  to 
break  the  angle  and  straighten  the  spine.  Other- 
wise such  a  ruinous  procedure  as  Forcible  Correction 
should  not  be  added  to  the  burden  of  traumatism 
which  the  tuberculous  spine  carries  as  the  centre  of 
motion  for  the  whole  body. 

Details  of  Mechanical  Support. — The  steel  brace  has 
a  feature  which  is  invisible,  and  yet  of  the  greatest 
importance  in  the  tractable  quality  of  the  metal  used. 
On  this  depend  the  efficiency  of  the  application  and 
the  comfort  of  the  patient.  To  secure  these  ends  in 
full  measure  requires  the  most  studious  attention. 
The  form  of  the  brace  before  its  application  will  be 
determined  in  a  general  way  by  the  shape  of  the  pa- 
tient's back,  and  yet  almost  at  once  the  latter  will  be 
changed  for  the  better  by  contact  with  the  brace  and 
in  turn  an  improvement  in  the  shape  of  the  brace 
will  be  seen  to  be  desirable  almost  immediately. 
Thus  the  patient's  figure  and  the  brace  will  alter- 
nately take  on  progressive  changes  by  a  series  of 
slight  but  imperative  modifications  of  the  apparatus 
which  require  the  frequent  exercise  of  skill  and  in- 
genuity. The  growth  of  the  child  will  call  for  some 
of  these  changes;  possible  diminution  of  the  angle 
will  determine  others.  Considerations  of  comfort 
will  lead  to  more  or  less  radical  alterations  in  the  ap- 
paratus. These  changes  may  be  sought  by  bending 
or  straightening  the  frame  of  the  brace,  by  substitut- 


TREATMENT  OF  POTT'S  DISEASE.      207 

ing  stronger  parts  for  those  that  have  come  to  be  too 
weak,  and  by  shifting  the  position,  direction,  and  ten- 
sion of  buckles  and  straps.  Too  much  attention 
cannot  be  given  to  the  ever-recurring  problems  which 
such  a  case  presents. 

Rule  for  Regulating  Pressure.— A  spinal  column 
yielding  under  the  weight  of  the  head  and  upper  part 
of  the  body  resembles  an  edifice  requiring  temporary 
support  while  necessary  repairs  are  being  made. 
But  the  spine  can  be  supported  only  by  pressure 
made  on  the  sensitive  and  easily  wounded  skin, 
which  interposes  an  imperative  and  serious  limit  to 
what  can  be  done  in  this  direction.  A  brace  is  in- 
deed an  outside  skeleton  like  those  of  the  crusta- 
ceans referred  to  on  page  54.  A  practical  rule 
therefore  formulates  itself  as  follows :  The  apparatus 
may  be  considered  as  having  reached  the  highest 
point  of  efficiency  when  it  makes  the  greatest  press- 
ure on  the  projection  compatible  with  the  integrity 
of  the  skin.  By  assiduous  care  and  attention  this 
seemingly  harsh  rule  may  be  strictly  observed  with- 
out compromising  in  any  degree  the  comfort  and 
convenience  of  the  patient.  If,  contrary  to  common 
prudence,  the  brace  is  fastened  in  place  at  once  as 
tightly  as  it  can  be  borne,  the  skin  wjll  immediately 
react  with  pain  and  ulceration.  But  if  the  pressure  is 
lightly  applied  at  first,  and  gradually  and  carefully 
increased  from  time  to  time,  it  will  be  found  as  the 


208  GRO  WTH  AND  DEFORMITY. 

weeks  and  months  pass  that  the  skin  will  have  be- 
come hardened  without  losing  its  integrity  or  caus- 
ing discomfort,  and  its  condition  will  indicate 
whether  or  not  the  patient  is  receiving  the  full  bene- 
fit of  mechanical  treatment.  It  has  been  proposed 
to  avoid  the  vulnerable  skin  and  support  the  deca- 
dent vertebrae  by  wiring  their  processes  together. 
The  suggestion  was  ingenious,  but  its  cleverness  did 
not  save  it  from  failure  through  structural  weakness 
of  the  young  and  recently  ossified  processes.  If, 
through  negligence,  abrasion  and  ulceration  occur, 
the  urgency  of  the  application  should  be  relaxed,  to 
be  resumed  later  with  more  watchfulness  and  care. 
An  affection  so  insidious  in  its  action  and  so  likely 
to  be  followed  by  disastrous  consequences  demands 
the  most  efficient,  albeit  difficult,  treatment. 

The  Plaster-of-Paris  Jacket. — It  may  be  questioned 
whether  a  process  so  laborious  and  involving  so 
many  nice  details  is  practicable,  whether  so  much 
time  can  rightfully  be  given  to  these  cases,  so  nu- 
merous in  an  orthopcedic  clinic.  The  serious  and  dis- 
abling effects  of  the  disease,  however,  cannot  but 
urgently  call  for  liberal  expenditure  of  effort,  which 
should  be  the  more  insistent  because  at  the  age  of 
these  patients  every  slight  betterment  represents  a 
more  conspicuous  gain  extending  into  adult  life. 
Other  methods  of  treatment,  including  forced  exten- 
sion in  the  prone  position  and  plastic  dressings,  may 


TREATMENT  OF  POTTS  DISEASE.      209 

not  be  strictly  governed  by  the  rule  proposed  for  the 
regulation  of  pressure.  Such  methods,  however,  are 
highly  commendable.  They  call  into  play  a  diffused 
pressure,  not  very  liable  to  wound  the  skin,  but  not 
readily  adjustable  in  degree  and  direction.  The  in- 
troduction of  the  plaster-of-Paris  jacket  especially 
has  conferred  benefit  on  vast  numbers  of  sufferers 
who  would  otherwise  have  been  denied  mechanical 
relief.  In  Pott's  disease,  as  in  all  orthopaedic  prac- 
tice, there  can  be  no  hard-and-fast  rules  as  to  the  de- 
sign or  material  used  in  the  apparatus.  No  method 
has  proved  to  be  better  than  all  others  on  every  occa- 
sion. Questions  of  detail  are  to  be  met  and  an- 
swered as  they  present  themselves,  and  no  case  will 
release  the  physician  from  the  necessity  of  studious 
and  persistent  readiness  to  meet  the  mechanical 
emergencies  as  they  arise.  In  the  upper  regions  of 
the  spine,  for  instance,  the  head  may  be  supported  by 
a  stock-like  collar,  or  a  jury  mast  with  flexible  rests 
for  the  chin  and  occiput,  or  a  less  conspicuous  un- 
yielding support  for  the  forehead  or  chin,  or  both. 
The  latter  may  rise  from  a  brace  provided  with  well- 
padded  curved  pieces  surmounting  the  shoulders. 
In  any  of  these  ways  the  weight  may  be  partly  re- 
moved from  the  spine  to  the  shoulders,  or  hips,  or 
transferred  to  the  posterior  section  of  the  column, 

with  comfort  and  advantage. 
14 


210       .       GROWTH  AND  DEFORMITY. 

RESULTS   AND   COMPLICATIONS. 

Among  the  results  of  Pott's  disease  is  Reduction  of 
Stature.  Valuable  tables,  showing  the  rate  of  growth 
in  spondylitics,  have  been  prepared  by  Dr.  H.  L. 
Taylor,  revealing  the  important  facts  that  the  rate 
of  growth  is  higher  for  patients  who  are  under 
strict  mechanical  treatment  and  efficient  manipula- 
tion, and  that  a  low  rate  calls  for  further  support,  or 
resumption  of  support,  if  it  has  been  discontinued. 
Reduced  height  is  caused  chiefly  by  the  shortening  of 
the  spinal  column.  It  is  supposed,  but  not  yet  demon- 
strated, that  an  important  cause  is  retarded  general 
growth  from  malnutrition  accompanying  the  disease. 
The  disproportion  in  the  lengths  of  the  trunk  and 
the  limbs  is  especially  seen  in  patients  who  would 
have  been  tall  men  and  women  if  the  spine  had  not 
been  shortened  by  disease.  In  the  act  of  sitting  the 
head  and  shoulders  of  such  a  patient  descend  >  until 
they  are  considerably  below  the  common  level,  as 
seen  in  Fig.  ii6.  This  has  led  to  the  suggestion 
that  prosthetic  apparatus  might  be  applied  to  lessen 
this  appearance.  In  Fig.  117  such  an  apparatus  is 
represented  as  supporting  the  trunk  with  the  head 
and  shoulders  near  the  normal  level.  Worn  under 
the  clothes,  it  should  collapse  when  the  wearer  rises, 
and  come  into  action  automatically  when  he  sits. 
Its  bearings  should  be  on  the  ischiatic  tuberosity  and 


CO  MP  Lie  A  TIONS  OF  PO  TT '  S  DISEA  SE.     2 1 1 


along  the  femoral  shaft,  the  parts  which  commonly 
receive  the  corporal  weight  in  the  sitting  position,  as 
seen  in  Fig.  118.  The  head  of  a  sitting  figure  is 
seen  in  Figs.  117,  118,  and  119,  at  about  its  normal 
altitude,  which  is  maintained  without  difficulty  by  a 
well  man,  whose  weight  falls  on  the  ischium  and  on 
the  shaft  of  the  femur.  But  a  patient  who  is  short- 
ened by  disease  can  keep  his  head  at  this  level  only 


Fig.   116. 
Figs.    116-119. 


Fig.    117. 


Fig     II: 


Fig.    iig. 


-Proposed   Device   for   Restoring   Height  in   the    Sitting 
Position  (1898). 


by  supporting  his  body  on  the  femoral  shaft,  at  the 
cost  of  considerable  effort  in  the  constrained  attitude 
seen  in  Fig.  119.  When  fatigue  finally  intervenes 
he  will  subside  into  the  easy  attitude  seen  in  Fig. 
116,  in  which  the  head  is  depressed  as  the  result  of 
his  spinal  shortening.  In  suitable  cases  this  may 
perhaps  be  prevented  by  the  apparatus  suggested, 
but  yet  to  be  constructed. 

Paraplegia. — An  occasional  and  very  troublesome 
complication  of  Pott's  disease  of  the  spine  is  para- 


212  GROWTH  AND  DEFORMITY. 

plegia,  occurring  early  or  late  in  the  disease,  accom- 
panying disease  of  the  upper  rather  than  the  lower 
regions,  varying  in  severity  from  slight  tremors  to 
the  inhibition  of  walking,  having  a  gradual  or 
sudden  beginning  with  no  recognizable  immediate 
cause,  produced  not  by  pressure  from  a  collection  of 
matter  or  deformed  bone,  but  rather  by  an  extension 
of  the  inflammation  to  the  membranes  of  the  cord, 
sometimes  of  brief  duration,  but  in  some  cases  con- 
tinuing a  very  long  time,  receding  gradually  or  ceas- 
ing suddenly,  recurring  repeatedly  in  some  cases, 
entirely  irresponsive  to  treatment  of  any  kind,  but 
ceasing  spontaneously  in  nearly  every  case,  and  sup- 
posed to  be  controlled  indirectly  to  some  extent  by 
mechanical  treatment  of  the  deformity.  The  study 
of  this  form  of  paralysis  led  Mr.  Pott  to  a  knowledge 
of  the  morbid  anatomy  of  the  disease  which  bears 
his  name. 

Cervical  Abscess. — Pott's  disease  is  not  often  a 
fatal  affection,  but  when  it  is  seated  in  the  upper 
regions  of  the  spine  the  addition  of  an  abscess  intro- 
duces an  element  of  danger.  The  vital  conduits 
converging  in  a  group  at  the  base  of  the  neck  are  in 
a  peculiar  position.  Some  of  them  transmit  blood 
to  and  fro;  others  provide  for  communication  be- 
tween the  brain  and  lower  parts  of  the  body,  and 
others  are  ducts  for  the  passage  of  air  and  nutritive 
ingesta.     At  this  point  they  are  collected  and  bound, 


CO  MP  Lie  A  riONS   OF  PO  TT '  S  DISEA  SE.     2 1 3 

as  in  a  sheaf,  by  muscular  and  fibrous  structures  and 
together  they  seek  admission  to  the  cavity  of  the 
chest  through  a  gate  formed  by  the  body  of  the  sec- 
ond dorsal  vertebra,  the  clavicles,  the  manubrium, 
and  the  first  and  second  ribs.  An  abscess  arising  in 
carious  bone  follows  the  direction  of  least  resistance. 
It  is  usually  harmless,  but  when  it  burrows  from  the 
cervical  vertebrae  downward  in  this  narrow  space  it 
is  a  menace  to  life.  It  is  not  probable  that  a  soft 
tumor  of  this  kind  can  fatally  occlude  the  trachea, 
whose  firm  walls  render  it  practically  incompressible 
except  by  severe  external  violence.  But  the  wind- 
pipe may  be  flooded  by  a  sudden  purulent  discharge 
into  the  pharynx,  or  fatal  spasm  of  the  glottis  may 
be  induced  by  interference  with  the  pneumogastric 
nerve.  It  is  not  easy  to  determine  the  immediate 
cause  of  sudden  death  in  cases  of  this  kind,  which 
give  rise  to  reasonable  anxiety  and  demand  an  early 
life-saving  operation. 

Psoas  Abscess. — In  another  region  a  burrowing 
abscess  may  cause,  not  a  fatal  event,  but  serious 
deformity  and  disability.  A  slight  contraction  of  a 
psoas  muscle,  indicating  the  migration  of  pus,  and 
being  perhaps  the  first  sign  of  Pott's  disease,  may  in- 
crease in  extent  and  firmness  until  it  leaves  the  pa-  ' 
tient  crippled  by  flexion  of  the  thigh,  not  unlike  that 
following  hip  disease,  differentiated  from  it  by  the 
presence  of  normal  motion  in  every  direction  except 


214  GROWTH  AND  DEFORMITY. 

extension,  and  responsive  to  similar  methods  of  treat- 
ment. The  presence  of  a  psoas  abscess  may  be 
detected  through  the  abdominal  wall  thoroughly  re- 
laxed by  flexion  of  the  thighs.  In  a  thin  patient  the 
lumbar  vertebrae  and  the  promontory  of  the  sacrum 
may  readily  be  made  out.  Comparing  the  two  sides 
deep  exploratory  palpation  will  show  that  the  iliac 
fossae  are  equally  clear  if  matter  is  absent ;  but  if  an 
abscess  is  taking  this  route,  the  hand  will  be  distinct- 
ly arrested  in  its  descent  into  the  iliac  fossa  of  one 
side.  In  other  regions  the  abscesses  of  Pott's  dis- 
ease are  insignificant.  They  may  be  treated  indi- 
rectly by  giving  strict  attention  to  the  welfare  of  the 
diseased  bone  in  which  they  have  their  origin.  As  in 
disease  of  the  hip  or  knee  the  result  of  a  case  of 
Pott's  disease  may  not  be  affected  by  direct  treat- 
ment of  this  complication. 

Case  XVIII. — Cold  Abscess  of  Uncertain  Origin. 
— A  girl,  twelve  years  old,  presented  in  May,  1902,  a 
strange  appearance  caused  by  a  fluctuating  tumor  of 
each  natis.  A  third  tumor,  which  simulated  hernia 
so  closely  that  a  truss  had  been  applied,  occupied  the 
left  groin.  Pressure  on  either  tumor  emptied  it  and 
increased  the  tension  of  the  others.  Pointing  pres- 
ently followed  in  the  groin,  and  an  eruption  occurred 
in  July  without  local  symptoms  or  the  appear- 
ance of  blood.  Collapse  of  the  tumors  followed  a 
great  discharge  of  the  fluid   common  in  cold  ab- 


CO  MP  Lie  A  TIONS  OF  PO  TT  S  DISEA  SE.     215 

scesses.  Treatment  was  expectant,  except  that  a 
plaster-of-Paris  jacket  was  worn,  unadvised,  for  sev- 
eral months.  The  sinus  closed  after  flowing  for  ten 
months,  leaving  a  scar  attached  to  Poupart's  liga- 
ment. The  tumors  were  thought  to  have  had 
their  origin  in  disease  of  the  lumbar  or  sacral  verte- 
brae. General  reaction  caused  anxiety  for  several 
months,  but  without  much  interference  with  the  pa- 
tient's activity  and  strength.  The  symptoms  grad- 
ually and  entirely  disappeared  during  a  vacation  in 
the  country.  Other  organs  escaped  disease,  and  in 
October,  1903,  menstruation  had  been  established 
and  health  was  completely  restored.  The  scar  and 
a  slight  typical  rotating  lateral  curvature  were  the 
only  abnormal  signs  found  in  July,  1904- 

Tuberculous  action  not  very  infrequently  produces 
in  the  sternum  an  anterior  deformity  analogous  to 
the  posterior  one  of  Pott's  disease. 

Case  XIX. — Caries  of  the  Sternum. — In  contin- 
uation of  Case  XIV.  (pp.  178,  179):  a  fluctuating  tu- 
mor appeared  over  the  upper  part  of  the  sternum  in 
December,  1880,  the  child  being  under  treatment  for 
disease  of  the  left  hip  in  the  third  stage.  A  month 
later  it  opened  spontaneously  with  discharge  of  puru- 
lent semi-fluid.  The  sinus  remained  open  for  two 
years  and  ten  months.  Six  years  after  it  closed  the 
resulting  scar  measured  two  inches  by  one  inch  and 
a  half.     It  was  superficial  except  at  a  depressed  point 


2i6  GROWTH  AND  DEFORMITY. 

where  it  was  attached  to  the  manubrium.  Caries 
at  the  junction  of  this  bone  with  the  gladiolus  had 
left  a  marked  deformity  with  a  salient  angle  of  one 
hundred  and  fifty  degrees.  The  disease  at  this 
point  was  attended  by  no  symptoms  and  required  no 
special  treatment.  It  pursued  its  course  while  the 
abscesses  connected  with  the  hip  were  alternating 
between  eruption  and  quiescence.  Their  final  clos- 
ure followed  that  of  the  sternal  sinus  after  an  inter- 
val of  five  years.  In  1895,  five  years  after  recovery 
from  hip  disease,  the  right  kidney  became  affected 
and  was  operated  on  in  July,  1897.  After  a  con- 
siderable interval,  in  which  the  young  woman  was 
active  and  bore  the  appearance  of  perfect  health, 
the  remaining  kidney  was  included  and  death  soon 
followed  in  January,  1900.  Her  mother  bore  scars 
from  early  disease  of  the  left  ankle  and  tarsus.  It 
would  seem  that  there  must  have  been  some  unde- 
tected reason  for  the  tenacity  of  the  tuberculous  pos- 
session in  this  case,  or  for  its  return  after  it  had  sur- 
rendered its  hold  on  the  bony  structures  of  the  hip 
and  thorax. 


CHAPTER  X. 
LATERAL   CURVATURE   OF   THE   SPINE. 

It  is  doubtful  whether  the  physicians  of  antiquity 
recognized  lateral  curvature  of  the  spine  as  a  distinct 
affection.  Cases  in  which  the  deformity  was  mode- 
rate they  probably  passed  over  as  unimportant,  and 
when  rotation  evolved  a  large  kyphosis,  as  it  does  in 
rare  instances,  they  may  have  resorted  to  the  crude 
methods  of  forcible  reduction  which  they  applied, 
regardless  of  pathological  conditions,  to  the  deform- 
ity of  Pott's  disease.  A  knowledge  of  vertebral 
caries  and  spinal  rotation  was  postponed  to  modern 
times.  The  latter  adds  a  peculiar  serpentine  ele- 
ment to  the  appearance  of  a  curving  spine  which 
could  hardly  have  escaped  the  attention  of  early  ob- 
servers, although  the  first  description  of  it  seems 
to  have  been  written  by  Dr.  Dods  in  1824.  The 
manner  of  its  production  has  been  the  subject  of 
ingenious  speculation  and  has  caused  many  honest 
differences  of  opinion  among  medical  men.  The  me- 
chanics of  this  interesting  puzzle  seem  to  elude  the 
understanding  very  much  after  the  manner  of  a  diffi- 
cult proposition  in  algebra.  For  this  reason  prob- 
ably the  true  explanation  of  this  phenomenon  failed 

217 


2l8 


GRO  WTH  AND  DEFORMITY. 


for  a  long  time  to  receive  general  recognition.  Many 
a  page  has  been  given  to  the  discussion  of  the  cause 
of  rotation,  which  would  have  been  unwritten  if  more 
weight  had  been  given  to  the  observation  that  when 
the  column  curves,  one  part  of  it  fails  to  move  lat- 
erally as  promptly  as  another  part.  The  tardy  por- 
tion is  the  posterior  section  which,  with  its  spinous 
and  other  processes,  is  incorporated  in  the  posterior 
wall  of  the  chest  and  abdomen.  The  freely  moving 
part   is   the   anterior  section,   where   the    vertebral 

bodies,  with  nothing  on  either 
side  to  interfere,  are  at  liberty 
to  move  either  to  the  right  or 
to  the  left  in  a  cavity  occupied 
by  unresisting  viscera.  The 
bisection  of  this  great  cavity 
into  two  deep  sulci  is  evident 
in  an  autopsy.  The  projec- 
tion into  it  of  the  spinal  col- 
umn is  seen  in  Fig.  120.  A 
hundred  times  a  day,  whenever  the  trunk  bends  for 
any  reason,  the  column  curves  and  the  vertebral 
bodies  swing  over  to  one  side  or  the  other  while 
the  processes,  being  restrained,  linger  near  the  me- 
dian plane.     The  result  is  rotation. 

A  tragical  illustration  of  this  action  of  the  spinal 
column  occurred  when  President  Garfield  fell  be- 
fore the  pistol  of  a  lunatic.     It  is  believed  that  the 


KiG.  120.  —  Horizontal 
Section  of  Trunk.  (Alex- 
ander Shaw,  1842.) 


ROTATING  LATERAL    CURVATURE.      219 


noise  of  the  first  shot  attracted  the  President's  atten- 
tion and  caused  him  to  look  behind  over  his  right 
shoulder.  Hastening  to  avoid  succeeding  shots  he 
strongly  bent  his  body  toward  the  left.  This  action 
threw  the  vertebral  bodies  far  to  the  right  where  they 
received  the  second  fire  directly  from  behind.  The 
direction  of  this  fatal  shot  is  represented  by  an  arrow 
in  Fig.  123.  When  the  victim  fell  from  concussion 
of  the  cord  the  straightening  column  gave  an  appar- 
ent deflection  to  the  track  of  the  ball.  Many  a  wild 
animal,  whose  vertebral  bodies  are  easily  found  by  a 
shot,  has  unexpectedly  gained  its  feet  and  escaped 
after  a  fall  thus  produced. 

Hypothetical  and  Actual  Vertebral  Rotation. — Rota- 
tion, in  general,  may  take  place  on  a  central,  on  a 
peripheral,  or  on  a  remote  or  foreign  axis.  This 
movement  on  a  central  axis 
is  seen  in  the  vertebra  rep- 
resented in  Fig.  121.  It  is 
evidently  not  the  rotation  of 
lateral  curvature.  Rotation 
on  a  peripheral  axis  is  per- 
formed by  the  vertebra  seen 
in  Fig.  122.  This  movement 
is  exemplified  in  those  cases  in     ^^'  ^^^'~  ^f^/^  .  °^^ '°^ 

^  on  a  Central  Axis. 

which   the   bodies  describe  a 

marked  curve,  while  the  spinous  processes  adhere  in 

a  straight  line  to  the  median  plane.     Aside   from 


220 


GROWTH  AND  DEFORMITY. 


these  exceptional  cases  vertebral  rotation  in  lateral 
curvature  takes  place  around  a  remote  axis,  as  is 


Fig.  122. — Vertebra  Rotating  on  a  Peripheral  Axis. 

shown  in  Fig.  123.  This  action  gives  to  all  sections 
of  the  vertebral  column  a  participation  in  the  curva- 
ture, which  is  greatest  in  the  anterior  section  and 


Fig.  123. — Vertebra  Rotating  on  a  Remote  Axis  (1876). 

least  in  the  posterior  section,  while  the  intermediate 
sections  have  more  curvature  as  the  anterior  limit  of 


ROTATING   LATERAL    CURVATURE.      221 

the  bones  is  approached  and  less  as  then-  posterior 
limit  is  approached. 

Rotating  curvature  is  seen  in  the  deportment  un- 


FiG.  124.— Spine  without  Curve  or 
Rotation. 


Fig.  125. — Rotating  Curvature. 


der  pressure  of  the  preparation  seen  in  Figs.  124, 
125,  and  126.  The  bones  are  kept  in  line  by  a  me- 
tallic rod  which  threads  the  round  fenestra,  made 


222 


GROWTH  AND  DEFORMITY. 


from  copper  wire,  which  is  seen  in  Fig.  127.  The 
position  of  the  rod  is  seen  in  Fig.  128.  It  is  flattened 
in  order  to  give  it  only  lateral  flexibility.  A  succes- 
sion of  spiral  wire  springs  serves  to  keep  the  poste- 


FiG.  126. — Double  Rotating  Curvature  (1876). 

rior  section  of  the  column  near  the  median  plane, 
just  as  it  is  restrained  in  the  living  body  by  being  a 
part  of  the  structures  composing  the  posterior  wall  of 


ROTATING  LATERAL    CURVATURE.      223 

the  cavity.  When  the  column  receives  downward 
pressure  it  exhibits  rotating  curvature,  seen  in  Fig. 
125,  and    when   the   middle   vertebra  is    restrained, 


Fig.  127.  Fig.  i: 

Figs.  127,  12S. — Isolated  Parts  of  Preparation  Seen  in  Fig.  124. 

there  is  a  compensating  curve  and  a  compensating 
rotation,  seen  in  Fig.  126,  as  they  occur  in  a  healthy 
or  in  a  diseased  spine. 

Rotation  and  Curvature  Inseparable. — Rotation  is 
not  only  a  constant,  "but  the  most  important,  feature 
of  the  deformity  from  every  point  of  view.  It  was 
formerly  a  question  whether  rotation  or  curvature 
was  the  primary  deviation ;  but  it  is  clear  that  they 
occur  together,  and  that  in  the  thoracic  and  abdomi- 
nal regions  the  spine  cannot  curve  without  rotation. 
Exceptions  to  this  are  thought  to  occur  in  the  de- 


224  GROWTH  AND  DEFORMITY. 

formity  which  follows  collapse  in  certain  serious  af- 
fections of  the  lungs.  It  is  also  clear  that  the  degree 
of  rotation  increases  and  decreases  with  the  degree 
of  curvature.  In  the  upper  dorsal  region  the  slight 
beginning  curve  to  the  right  is  marked  by  a  begin- 
ning rotation,  in  which  the  body  of  the  vertebra  is 
displaced  farther  toward  the  right  than  the  processes. 
Lower  down  the  curvature  and  the  rotation  increase 
with  equal  steps,  and  then,  the  extreme  being  passed, 
they  decrease  together  till  a  neutral  point  is  reached. 
Here  there  is  no  curvature.  The  vertebra  at  this 
point  is  in  equilibrium  in  the  median  plane  with  'ro- 
tation neither  to  the  right  nor  to  the  left.  Passing 
below  the  neutral  point  there  is  a  curve  to  the  left  in- 
stead of  to  the  right,  marked  by  rotation  opposite,  of 
course,  to  that  found  above.  Farther  down  still,  the 
compensating  curvature  and  the  compensating  rota- 
tion increase  together  in  the  lower  dorsal  and  lumbar 
regions,  and  then  they  decrease  till  they  disappear 
together  in  the  lower  lumbar  and  sacral  vertebrae. 
The  whole  forms  the  sigmoid  curve,  to  which  rota- 
tion imparts  a  graceful  and  animating  sinuosity. 

The  Internal  Greater  Than  the  External  Curve. — 
As  the  anterior  section  of  the  column  departs  farther 
from  the  median  plane  than  the  posterior  section,  the 
full  extent  of  the  deviation  is  not  indicated  by  the 
curve  seen  in  the  line  of  the  spinous  processes.  If 
these  show  a  marked  curve,  it  is  certain  that  the 


DM  GNOSIS  OF  LA  TERAL  CUR  VA  TURE.     225 

bodies  execute  a  still  greater  curve,  unseen,  in  the 
cavity.  Cases  are  not  infrequently  observed,  exem- 
plifying rotation  on  a  peripheral  axis,  in  which  the 
processes  show  absolutely  no  deviation,  while  the 
curving  of  the  bodies  throws  the  ribs,  the  scapulae, 
and  the  transverse  processes  into  asymmetry.  It  is 
noteworthy  that  the  Effect  of  Rotation  on  the  Torso  has 
been  overlooked  by  ancient  and  modern  sculptors  of 
the  nude  figure.  When  the  trunk  bends  laterally, 
rotating  curvature  of  the  spine  brings  into  promi- 
nence unexpected  masses  of  muscle,  which  would 
have  given  action  where  it  is  missing  in  the  marble 
and  bronze,  although  seen  in  the  gymnasium.  It  is 
traceable  in  the  bodies  of  leopards  and  such  animals 
when  they  turn  the  corners  of  their  narrow  cages 
where  it  lends  a  subtle  grace  to  their  serpentine 
promenades. 

DIAGNOSIS. 

Misleading  Tumors  Caused  by  Rotation. — Rotation 
not  only  throws  into  relief  unexpected  masses  of 
muscular  fibres,  but  it  also  is  responsible  for  a  variety 
of  mysterious  tumors  which  stand  ready  to  lead  the 
most  wary  diagnostician  astray.  In  the  celebrated 
case  of  Dr.  Gideon  Mantell,  whose  spinal  curvature 
was  recognized  only  post  tnortem,  rotation  produced 
what  seemed  to  be  an  abscess  in  the  lumbar  region, 

which  Mr.  Liston  was  prepared  to  open,  with  the 

15 


226  GROWTH  AND  DEFORMITY. 

acquiescence  of  Mr.  Brodie.  Other  consultants 
thought  it  was  a  lobulated  tumor  connected  with  the 
bodies  of  the  vertebrae.  As  time  passed,  and  as  no 
change  appeared  in  the  tumor,  it  was  suggested  that 
"  the  matter  was  becoming  firmer  or  concrete,  and 
that  the  abscess  was  incHned  to  shrink,  as  abscesses 
sometimes  do,  and  disappear."  Cases  are  recorded 
in  which  aspiration  had  been  tried  in  vain,  and 
others  in  which  evacuation  had  been  advised  and 
postponed.  In  the  case  of  a  patient  who  was  pre- 
sented to  a  medical  society,  a  tumor  was  said  by 
one  observer  to  be  cystic  and  by  another  an  en- 
largement of  the  spine  of  the  scapula.  Another 
speaker  said  that  on  a  previous  occasion  it  had  dis- 
appeared under  an  anaesthetic,  leaving  the  inference 
that  it  was  the  result  of  muscular  spasm.  It  was  in 
fact  a  muscular  mass  brought  into  prominence  by 
spinal  rotation.  Advancement  of  the  left  side  of  the 
chest  gives  to  the  mammary  gland  the  appearance  of 
hypertrophy,  while  a  more  accentuated  prominence 
over  the  cardiac  region  simulates  the  deformity  caused 
by  an  aneurysmal  tumor.  In  Dr.  Mantell's  case  the 
curvature  was  confirmed  by  changes  in  the  shape  of 
the  bones,  and  the  tumor  was  permanent.  This  is  true 
in  regard  to  some  of  the  misleading  tumors  men- 
tioned. Others  of  them,  however,  are  transient,  alter- 
nately appearing  and  vanishing  with  changes  in  the 
patient's  attitude,  which  now  produce  curvature  and 


DIAGNOSIS   OF  LATERAL    CURVATURE.     227 

rotation,  and  again  cause  them  to  disappear.  When 
the  tumors  caused  by  rotation  affect  this  elusive 
quahty  they  may  be  regarded  as  phantoms. 

Recognition  of  Rotation. — It  is  important,  therefore, 
to  be  able  to  eliminate  the  influence  of  rotation  when 
considering  certain  tumors  of  doubtful  origin.  A 
useful  diagnostic  method  may  be  practised  by  palpa- 
tion of  the  chest  between  the  palms,  which  may  re- 
veal a  longer  diagonal  diameter  in  one  direction  than 
in  the  other,  thus  betraying  rotation  even  in  cases  in 
which  the  spinous  processes  are  in  a  straight  line. 
When  rotation  makes  prominent  the  angles  of  the 
ribs  on  the  right  side  behind,  the  same  movement 
brings  out  a  prommerux  on  the  left  side  of  the  chest 
in  front.  An  increase  in  the  diagonal  diameter  in 
this  (the  first)  direction  is  thus  produced.  At  the 
same  time,  the  same  movement  of  rotation  depresses 
the  angles  of  the  ribs  on  the  left  side  behind,  and  also 
flattens  the  right  side  of  the  chest  in  front.  A  de- 
crease of  the  diagonal  diameter  in  this  (the  second) 
direction  is  thus  caused.  Since  the  same  movement 
of  rotation  increases  one  diameter  and  decreases  the 
other,  a  very  moderate  amount  of  rotation  may,  and 
often  does,  produce  a  difference  in  these  diameters 
which  is  readily  detected  by  bimanual  compression  of 
the  chest  applied  diagonally,  first  in  one  direction  and 
then  in  the  other.  With  care  the  presence  of  a  very 
slight  rotation  may  be  detected  in  this  way. 


228 


GROWTH  AND  DEFORMITY. 


Aside  from  occasional  doubt  as  to  the  origin  of 
some  of  the  results  of  rotation,  the  recognition  of 
lateral  curvature  is  a  simple  matter.  In  the  absence 
of  symptoms  and  general  reaction,  diagnosis  depends 

wholly  on  want  of  sym- 
metry, which  is  first  seen 
in  the  shoulders  or  hips,  in 
many  cases  by  a  casual  ob- 
server after  an  indefinite 
duration. 

Sciatica. — Since  it  is  cus- 
tomary in  orthopaedic  work, 
and  especially  in  lateral 
curvature,  to  lay  more  stress 
on  signs  than  on  symptoms, 
it  is  well  to  consider  a 
peculiar  spinal  deviation 
accompanying  sciatica.  In 
this  affection  the  subjective 
symptom  of  pain  should 
overshadow  all  else,  but  it  is 
accompanied  by  a  deform- 
ity, or  spinal  deviation,  remarkably  suggestive  of 
lateral  curvature,  with  a  distinct  displacement  of 
the  axis  of  the  chest  forward  and  to  the  opposite 
side,  as  in  Fig.  129.  This  patient,  a  professional 
man,  forty-seven  years  of  age,  suffered  severely 
from  sciatica.     When  the  photograph  was  taken  he 


Fig.  129  — Right  Sciatica  Sim- 
ulating Sacro-iliac  Disease 
and  Lateral  Curvature  (1885). 


DIAGNOSIS  OF  LATERAL    CURVATURE     229 

had  been  disabled  for  eight  months.  Ten  months 
later  he  unexpectedly  recovered,  after  having  re- 
ceived a  great  variety  of  advice  and  treatment  in 
different  parts  of  the  country.  Pain,  disability,  and 
spinal  deformity  were  absent  after  his  recovery,  until 
he  died  of  disease  of  the  kidneys,  after  a  short  illness 
at  the  age  of  fifty-four.  It  is  noteworthy  that  the 
displacement  of  the  axis  of  the  chest  was  always  to 
the  left,  and  never  to  the  right,  and  that  the  patients 
were  men,  in  a  number  of  observed  cases,  as  well  as 
in  the  photographs  in  which  a  peculiar  deviation  is 
seen  in  the  treatises  of  Sayre,  Moore,  Whitman, 
and  others.  The  painful  symptoms  may  extend  to 
the  toes,  arresting  passive  extension  of  the  knee 
when  the  hip  is  flexed,  and  flexion  of  the  hip  when 
the  knee  is  extended.  A  spinal  deviation  having 
this  origin  may  be  useful  as  a  diagnostic  sign. 

Sacro-iliac  Disease. — It  is  important  to  note  that 
the  attitude  of  the  patient  in  sciatica  and  his  inabil- 
ity or  disinclination  to  use  the  affected  limb  may 
lead  to  a  mistaken  diagnosis,  not  only  of  lateral  cur- 
vature of  the  spine,  but  also  of  sacro-iliac  disease. 
This  affection  is  allied  on  one  side  with  Pott's  dis- 
ease and  on  the  other  side  with  hip  disease.  It  may 
receive  neither  the  mechanical  support  which  Pott's 
disease  requires  nor  protection  from  the  weight  of 
the  body  by  ischiatic  support.  A  suitable  mechani- 
cal environment  for  a  tuberculous  sacro-ili^c  joint  is 


230  GROWTH  AND  DEFORMITY. 

to  be  found  therefore  only  in  recumbency.  It  is  not 
easy  to  see  why  this  disease  is  so  rare  when  cases  of 
the  two  affections  with  which  it  is  aUied  are  so  com- 
mon. An  explanation  may  be  hazarded  as  follows: 
When  the  case  is  mild,  the  stability  of  the  affected 
bones  and  their  relation  of  mutual  support  may  lead 
to  recovery  before  the  disease  is  recognized;  and 
when  the  case  is  severe,  disability  doubtless  compels 
a  resort  to  recumbency,  which  in  time  may  lead  to 
recovery  before  a  positive  diagnosis  can  be  made. 
The  recognition  of  this  disease  is  exceptionally  diffi- 
cult on  account  of  the  deep  situation  and  the  immo- 
bility of  the  joint.  It  has  been  frequently  said 
that  the  affection  is  likely  to  be  complicated  by  ab- 
scesses, and  that  it  has  a  generally  unfavorable  prog- 
nosis. Further  knowledge  is  necessary  before  these 
statements  may  be  accepted  as  beyond  question. 

Various  Theories  of  Rotation. —  Many  explanations 
of  the  occurrence  of  rotation  have  been  presented. 
It  was  formerly  held  that  one  of  the  functions  of  the 
articular  processes  was  to  prevent  undue  lateral 
excursions  of  the  bodies  of  the  vertebrae,  and  that 
pressure  from  a  faulty  position  too  long  continued 
would  change  their  shape  and  allow  the  bodies  to 
rotate  from  the  want  of  customary  lateral  opposition. 
Rotation  was  thus  made  to  appear  as  the  result  of  a 
morbid  change  in  the  vertebrse  themselves,  and  not 
of  influences  derived  from  their  relation  to  the  wall 


DIAGNOSIS  OF  LATERAL    CURVATURE.     231 

of  the  cavity.  According  to  this  view,  if  the  left  su- 
perior articular  process  of  the  ninth  dorsal,  for  in- 
stance, yields  to  pressure  and  allows  the  left  side  of 
the  eighth  to  advance,  the  same  yielding  would  allow 
the  left  side  of  the  ninth  to  recede,  and  there  would 
be  no  disturbance  either  way,  and  of  course  no  rota- 
tion; and  as  the  inferior,  as  well  as  the  superior, 
processes  must  yield  to  absorption  from  pressure,  the 
ninth  will  rotate  toward  the  left  in  obedience  to  the 
absorption  of  its  superior  process,  and  at  the  same 
time  toward  the  right  in  response  to  the  giving  way 
of  its  inferior  articulating  process,  and  there  would 
be  no  rotation  in  either  direction.  The  cause  of  this 
movement  may  be  sought,  not  in  changes  in  the  ver- 
tebrae themselves,  but  rather  in  a  foreign  agent,  such 
as  mural  limitation  of  the  mobility  of  the  spinous 
processes.  It  has  also  been  thought  that  the  ante- 
rior part  of  the  column  has  expansibility,  and  the 
posterior  part  compressibility,  and  that  in  curvature 
the  expanding  bodies  seek  the  convexity  where  there 
is  less  pressure,  leaving  the  compressed  processes  in 
the  concavity  where  there  is  more  pressure;  but 
these  spinal  motions  are  so  sharp  and  distinct  that 
they  could  not  be  produced  in  this  way. 

At  a  meeting  of  the  British  Medical  Association 
held  in  1864,  it  was  suggested  that  "the  twisting  is 
purely  the  mechanical  consequence  occasioned  in 
the  deviated  or  curved  spine  by  bending  it  forward." 


232 


GROWTH  AND  DEFORMITY. 


In  criticism  of  this  theory  it  may  be  recalled  that  the 
spine  bent  forward  and  at  the  same  time  laterally 
may  not  be  said  to  have  two  curves,  one  antero- 
posterior and  the  other  lateral,  but  rather  one  curve 


Fig.  130. 


Fig.  131. 


Fig.  132. 


Fig.  133. 


Figs.  130-133. — Rotation  not  Affected  by  the  Flexion  or  Extension  of  the 
Curved  Spine  (1901). 


produced  by  the  resultant  of  two  forces,  one  acting 
antero-posteriorly  and  the  other  laterally.  The  curve 
thus  produced  is  partly  antero-posterior  and  partly 
lateral,  but  it  is  still  a  simple  curve,  and  as  such  it 


DIAGNOSIS  OF  LATERAL    CURVATURE.     233 

has  no  power  to  initiate  a  rotary  movement.  Fig.  130 
represents  an  imitation  of  the  vertebral  column  made 
of  India  rubber,  in  order  to  determine  whether  antero- 
posterior variations  of  the  spine  do  or  do  not  ex- 
ert an  influence  on  the  production  of  the  rotation 
which  accompanies  lateral  curvature.  The  central 
pin  is  presented  point  blank  to  the  camera  in  each 
exposure  in  order  to  secure  the  same  point  of  view 
throughout  the  series.  Fig.  131  shows  a  lateral  curve 
without  flexion  or  extension,  Fig.  132  shows  a  lateral 
curve  with  flexion,  and  Fig.  133  shows  a  lateral  curve 
with  extension.  Rotation  does  not  appear  in  the 
series,  except  in  Fig.  133.  In  this  figure  a  careless 
arrangement  of  the  object  before  the  camera  has 
given  a  quartering  view  of  the  central  pin,  which  has 
resulted  in  what  appears  to  be  a  slight  rotation  of  the 
column.  The  effect  of  this  mistake  does  not  vitiate 
the  demonstration  that  rotation  is  independent  of 
flexion  or  extension.  It  simply  calls  attention  to  the 
necessity  of  holding  the  same  point  of  view  in  the 
different  members  of  such  a  series. 

The  True  Theory  of  Rotation.— To  find  the  cause 
of  rotation  the  attention  may  be  directed  away  from 
the  column  itself  and  its  vertebrae.  It  has  no  intrin- 
sic attributes  inclining  it  to  rotate,  and  no  relation  of 
some  of  its  parts  to  others  that  can  contribute  to  the 
production  of  this  peculiar  action.  The  cause  of 
rotation  is  aptly  explained  by  a  reference  to  the  ex- 


234  GROWTH  AND  DEFORMITY. 

trinsic  agency  of  the  chest  wall,  which  imposes  a  re- 
straint on  a  part  of  the  spine  without  affecting  other 
parts.  This  theory  is  in  accord  with  all  the  con- 
ditions found.  It  explains  the  facts  that  rotation 
attends  the  transient  curves  of  health  and  the  con- 
firmed curvature  of  disease,  that  it  is  absent  in  the 
cervical  region,  and  that  it  crosses  the  median  plane 
in  company  with  the  compensating  curve.  The  ob- 
servation made  in  1876  that  rotation  was  produced 
in  this  way  was  thought  to  be  new,  but  Mr.  Noble 
Smith,  in  1882,  referred  to  the  work  of  Mr.  Rogers- 
Harrison,  who  made  the  same  observation  in  1842. 
It  is  so  simple,  when  it  is  apprehended,  and  such  a 
complete  and  satisfactory  interpretation  of  a  common 
clinical  incident  that  it  has  probably  occurred  to 
others,  and  very  likely  may  be  found  in  writings  be- 
fore the  time  of  Mr.  Rogers- Harrison. 

Incidental  Rotating  Curvature,  when  it  occurs  as 
the  result  of  an  habitual  one-sided  attitude  or  carriage 
of  the  body,  may  be  sufficiently  arrested  by  timely  cor- 
rection of  the  bad  habit.  It  is  assumed  in  an  uncon- 
scious effort  to  maintain  equilibrium  menaced  by  the 
loss  of  an  arm  or  the  collapse  of  a  lung.  It  accom- 
panies shortening  of  a  leg  by  accident  or  disease,  and 
may  then  be  lessened  or  removed  by  factitious 
lengthening  of  the  short  limb,  as  in  Figs.  108  and 
109  (p.  181),  where  compensation  is  made  by  a  book 
placed  under  the  foot. 


TREA  TMENT  OF  LA  TERAL  CUR  VA  TURE.     235 

Typical  Lateral  Curvature. — The  greater  number  of 
cases,  however,  occur  without  any  known  cause,  ex- 
cept such  as  may  be  found  in  muscular  inabihty  to 
sustain  the  impending  weight,  which  overcomes  the 
spine  and  causes  it  to  sag  more  and  more  till  it  pre- 
sents an  instance  of  typical  lateral  curvature.  The 
etiology  of  this  affection  remains  obscure,  and  its 
treatment  is  still  so  unsatisfactory  that  when  the  de- 
formity is  confirmed  by  changes  in  the  bones  it  is 
generally  believed  to  be  beyond  the  reach  of  any 
attempts  at  reduction.  It  is  fortunate,  therefore,  that 
the  affection  does  not  compromise  longevity  or  in- 
terfere with  a  life  of  industry  and  activity.  It  might 
be  argued,  but  not  too  seriously,  that  a  lateral  cur- 
vature is  an  agreeable  departure  from  conventional 
symmetry,  an  attractive  feature,  to  be  placed  in  the 
same  category  with  a  slight  cast,  or  squint,  which 
has  been  thought  to  add  piquancy  to  a  regular  face. 
It  may  not  be  denied  that  it  repeats  the  curved  line 
of  beauty,  or  that  rotation  carries  an  expression  of 
serpentine  grace. 

TREATMENT. 

Although  it  may  not  be  possible  to  make  an  es- 
tablished curvature  disappear,  careful  treatment 
may  be  expected  partly  to  reduce  the  deformity  or 
to  render  it  less  noticeable.  Especially  should  treat- 
ment be  thorough  when  a  case  shows  any  indication 


236  GROWTH  AND  DEFORMITY. 

of  assuming  a  rare  form  in  which  the  angles  of  the 
ribs  are  pushed  backward  by  rotation  until  the  re- 
sulting kyphosis  rivals  that  of  a  neglected  case  of 
Pott's  disease.  It  may  not  be  concluded  because  the 
deformity  of  lateral  curvature  is  not  as  a  rule  offen- 
sive, or  attended  with  disability  and  danger  to  life, 
that  the  treatment  of  this  affection  is  to  be  lightly 
considered.  The  possibility  of  an  excessive  protru- 
sion of  the  angles  of  the  ribs  should  be  in  the  mind, 
to  encourage  earnest  and  careful  treatment.  When 
one  of  these  rare  cases  is  fully  developed,  an  exten- 
sive and  very  prominent  kyphosis,  quite  near  the 
middle  line  of  the  back,  has  its  profile  made  up  by  a 
succession  of  accentuated  angles  of  rotated  ribs,  and 
not,  as  in  Pott's  disease,  by  the  projection  of  the 
spinous  processes  of  carious  vertebrae.  The  de- 
formed and  deflected  processes  may,  with  care,  be 
isolated  and  counted  near  the  crest  of  the  costal 
kyphosis  and  almost  overhung  by  it.  The  stature  is 
reduced  by  a  descent  of  the  thorax  and  its  lodgment 
on  the  pelvic  bones,  as  in  Pott's  disease.  This  con- 
dition is  serious  enough  to  call  for  every  resource  of 
watchfulness,  prevention,  and  treatment. 

The  wish  is  often  expressed  that  apparatus  could 
be  so  made  that  it  would  do,  with  certain  plastic  de- 
formities, what  can  be  done  so  easily  by  the  hands. 
It  would  seem  that  rotation  could  be  diminished, 
temporarily   at.  least,  by  rolling   the   chest  forcibly 


TREA  TMENT  OF  LA  TERAL  CUR  VA  TURE.     237 

between  the  palms,  but  it  is  at  present  beyond  the 
power  of  mechanical  therapeutics  to  produce  and 
prolong  this  effect,  and  especially  to  oppose  simulta- 
neously the  primary  and  the  secondary  deviations. 
If,  however,  either  curve  could  be  reduced  in  this 
way,  compensation  would  bring  the  whole  column 
into  a  straight  line. 

Antero-Posterior  Pressure. — For  many  years  the 
opinion,  which  received  the  early  advocacy  of  Dr. 
Lee,  has  been  under  consideration  that  antero-poste- 
rior  pressure,  long  continued  and  forcible,  would  be 
curative  in  lateral  curvature,  as  it  is  in  Pott's  disease, 
by  transferring  the  pressure  of  superincumbent 
weight  from  the  anterior  to  the  posterior  section  of 
the  column.  There  is  a  suggestive  analogy  in  the 
relations  of  the  vertebrae  in  the  two  affections.  In 
Pott's  disease  the  anterior  part  of  the  bone  is  carious, 
and  a  brace  transfers  pressure  to  its  posterior  part, 
which  is  unaffected.  In  lateral  curvature  the  ante- 
rior portion  departs  from  the  median  plane,  and  a 
brace  might  transfer  pressure  to  the  posterior  por- 
tion, which  adheres  to  the  median  plane.  Further- 
more, pressure  applied  directly  from  behind  would 
meet  the  transverse  processes  of  the  convex  side 
which  are  rotated  backward,  before  it  could  reach 
those  of  the  concave  side,  which  are  rotated  forward. 
It  would  therefore  directly  and  positively  oppose 
rotation.     The  plan  is  certainly  attractive  from  a  me- 


238  GRO  WTH  AND  DEFORMITY. 

chanical  point  of  view.  When  a  trial  of  it  was  made 
in  1876  and  1877  it  was  found  to  be  easily  practicable. 
It  was  diflficult,  however,  to  continue  the  treatment 
long  enough  to  note  whether  it  could  be  relied  on  to 
produce  positively  favorable  results.  The  method 
would  be  justified  and  commendable  if  the  pathology 
and  prognosis  of  this  affection  were  as  serious  as 
those  of  Pott's  disease.  This  plan  may  be  compared 
and  contrasted  with  the  common  method  of  making 
lateral  pressure  on  the  projecting  ribs,  which  is  open 
to  the  objection  that  although  such  pressure  is  to  all 
appearances  reasonably  applied  to  reduce  an  obvious 
projection,  it  is  applied  to  the  ribs,  which  show  an 
incidental  deformity,  and  not  to  the  curving  spine, 
which  is  the  seat  and  origin  of  the  trouble.  A  re- 
view of  the  anatomy  of  the  part  recalls  the  fact  that 
the  ribs  are  attached  to  the  spine  so  near  to  its  poste- 
rior and  so  far  from  its  anterior  section  that  pressure 
on  them,  applied  with  any  degree  of  force,  would  in- 
crease rotation  or  at  least  prevent  its  reduction.  If 
pressure  could  be  made  by  invading  the  cavity 
(which  is  as  yet  impossible),  and  pushing  laterally  and 
forcibly  against  the  bodies  of  the  vertebrae,  it  is  con- 
ceivable that  both  curvature  and  rotation  could  be 
opposed  by  one  motion. 

Treatment  Based  on  Clinical  Observations. — It  seems 
proper,  therefore,  to  decline  to  make  the  application 
of  a  brace  the  rule  of  practice,  subject  of  course  to 


TREA  TMENT  OF  LA  TERAL  CUR  VA  TURE.     239 

the  proverbial  exceptions  which  are  said  to  prove  a 
rule.  But  something  should  be  undertaken  not  to 
reduce  the  curvature  entirely,  which  is  very  seldom 
done,  but  to  modify  it  and  its  incidental  deformities 
and  to  prevent  an  increase  of  the  trouble. 

Recumbency. — In  the  course  of  clinical  observa- 
tions it  is  evident,  at  the  first  examination,  that  the 
curvature  is  diminished  when  the  weight  of  the  up- 
per part  of  the  body  is  removed  by  recumbency  in 
the  prone  position.  Rotation  and  its  incidental  de- 
formities also  largely  disappear  with  the  curvature. 
But  these  phenomena  return  in  full  force  when  the 
patient  rises.  These  changes  doubtless  take  place 
unseen  when  standing  alternates  with  the  supine 
position,  which  hides  the  back  from  view.  It  follows 
that  a  growing  child,  affected  with  lateral  curvature, 
should  be  led  to  occupy  the  recumbent  position  as 
much  of  the  time  as  possible,  so  that  the  increment 
incidental  to  natural  growth  may  be  correctly  placed 
and  favor  symmetry.  "Just  as  the  twig  is  bent,  the 
tree's  inclined." 

The  question  has  been  debated  whether  this  affec- 
tion could  occur  in  a  child  whose  attitude  from  birth 
had  been  absolute  and  uninterrupted  recumbency. 
If  downward  pressure  by  the  weight  of  the  upper 
part  of  the  body  were  the  only  direct  cause,  there 
could  of  course  be  no  lateral  curvature  in  a  child  who 
had  never  been  placed  in  the  erect  position.     But 


240  GROWTH  AND  DEFORMITY. 

muscular  contraction  is  also  to  be  counted  as  one  of 
the  direct  causes.  It  may  be  recalled  that  the  mus- 
cles of  the  trunk  assume  a  general  tonic  condition 
when  any  considerable  movement  is  made  elsewhere, 
in  order  to  afford  a  firm  base  of  action  for  motions  of 
the  head  or  in  the  extremities.  Probably  very  few 
movements  take  place  in  any  part  of  the  body  with- 
out a  longitudinal  compression  of  the  spine.  This 
would  favor  the  production  of  lateral  curvature  as 
certainly  as  compression  made  by  the  weight  of  the 
head  and  upper  part  of  the  body. 

Muscular  contraction  has,  however,  a  limited  effect 
in  this  direction,  and  superincumbent  weight  must 
still  be  considered  as  the  principal  direct  cause  of 
lateral  curvature.  Recumbency,  practised  several 
hours  daily,  is  therefore  to  be  retained  as  an  impor- 
tant part  of  systematic  treatment.  In  the  supine 
position  an  air  pillow,  inflated  to  an  increasing  de- 
gree as  the  patient  becomes  accustomed  to  its  use, 
should  occupy  such  a  position  under  the  back  as  to 
maintain  lordosis.  This  may  be  considered  as  an 
imitation  of  the  effect  of  the  proposed  antero-poste- 
rior  brace,  the  action  of  which  transfers  pressure 
from  the  more  affected  to  the  less  affected  section  of 
the  spine.  This  position  should  be  maintained  dur- 
ing sleep  so  far  as  is  practicable.  An  air  pillow  of 
convenient  size  is  "  No.  2,"  which  measures  about 
eighteen  inches  by  ten  inches. 


TREA  TMENT  OF  LA  TERAL  CUR  VA  TURE.     241 

Suspension. — Observations  being  resumed,  it  is 
seen  that  the  curvature  disappears  even  more 
promptly  and  completely  when  the  patient  suspends 
herself  from  an  overhead  bar  than  when  she  lies 
down,  and  that  when  the  hands  relinquish  the  bar 
there  is  a  sudden  return  of  the  curvature  and  all  of 
its  incidental  deformities.  Suspension  should  there- 
fore be  added  to  the  list  of  important  therapeutic 
agents.  There  should  be  no  muscular  effort  beyond 
that  required  to  keep  the  fingers  flexed  on  the  bar. 
The  body  may  swing  gently  in  suspension,  as  a 
means  of  timing  the  exercise,  seven  vibrations  back- 
ward and  forward  measuring  one-quarter  of  a  minute, 
which  is  long  enough  for  each  effort  at  the  begin- 
ning. A  simple  doorway  bar  may  be  conveniently 
used  for  a  number  of  exercises,  half  a  dozen  or  so, 
with  suitable  intervals,  on  rising  in  the  morning. 
More  time  and  effort  may  be  expended  at  bedtime, 
to  be  followed  by  the  night's  rest.  In  the  routine  of 
the  day  the  bar  should  be  in  use  as  much  as  is  prac- 
ticable. The  customary  apparatus  for  suspension 
by  the  head  and  the  axillae  will  give  facility  and  thor- 
oughness to  these  exercises. 

Chest   Expansion. ^It   will   be   observed   that   the 

chest  is  expanded  during  suspension.     The  sternal 

ends  of  the  ribs  being  attached  to  the  bar  through 

the  intervention  of  the  arm,  forearm,  and  hand,  their 

vertebral  ends  are  drawn  downward  by  the  weight  of 
16 


242 


GRO  WTH  AND  DEFORMITY. 


the  body  and  lower  limbs,  producing  forced  inspira- 
tion in  a  very  positive  manner.  The  effect  of  deep- 
ening and  facilitating  inspiration  by  the  practice  of 
suspension  has  received  well-merited  attention.     Dr. 

Henry  G.  Davis  made  it  a 
part  of  a  method  by  which 
he  believed  that  he  had 
demonstrated  the  curabil- 
ity of  phthisis  pulmonalis. 
The  physiological  and  me- 
chanical  considerations 
which  give  to  suspension 
its  value  as  a  means  of  de- 
veloping the  chest  are  illus- 
trated in  Sylvester's  meth- 
od of  resuscitating  those 
about  to  perish  by  asphyx- 
iation. It  may  also  be 
recalled  that  audible  sus- 
piration  is  made  when  the 
conditions  are  favorable  by 
a  cadaver  drawn  up  and  laid  supine  on  the  floor 
of  the  dissecting-room,  after  transit  from  below 
while  suspended  by  the  arms.  It  is  said  that  pa- 
tients seek  relief  in  asthmatic  paroxysms  by  grasp- 
ing the  top  of  a  door  in  the  absence  of  a  more 
convenient  support.  Dr.  French,  of  Portland,  Maine, 
in    1877   introduced  a   respiratory  brace,  shown   in 


Fig.  134. — Respiratory  Brace  for 
Orthopnoea.     (Dr.  French,  1877.  J 


TREA  TMENT  OF  LA  TERAL  CUR  VA  TURE.     243 

Fig.  134,  for  the  relief  of  orthopnoea.  With  this 
device  in  use  suspension  may  be  conveniently  grad- 
uated in  severity  as  the  patient  is  seated  and  can 
at  will  put  more  or  less  of  his  weight  on  the  sup- 
porting straps.  Suspension  applied  as  a  part  of 
the  treatment  of  lateral  curvature,  coinciding,  as  it 
will,  with  the  period  of  growth,  may  reasonably  be 
expected  to  produce  a  lasting  effect  on  the  size  of  the 
thorax  and  capacity  of  the  lungs.  This  accession  of 
respiratory  ability  cannot  but  react  favorably  on  the 
general  health  and  especially  on  the  muscular  sys- 
tem, whose  failure  is  apparently  a  link  in  the  chain 
of  causes  of  lateral  curvature.  A  further  considera- 
tion of  this  form  of  exercise  will  also  show  that  it 
provides  what  has  been  most  diligently  sought,  a 
Method  of  Directly  Opposing  Rotation,  an  element  of 
the  deformity  which  lateral  pressure  from  without  is 
unable  to  affect,  except  adversely.  Suspension  op- 
poses rotation  from  within  by  overfilling  or  inflat- 
ing, by  a  forced  development  of  its  contents,  the  cav- 
ity upon  which  rotation  encroaches. 

Rest. — Observations  being  resumed,  it  will  be  seen 
sooner  or  later  that  fatigue  or  weakness  increases  the 
appearance  of  deformity.  During  an  indisposition, 
or  after  a  long  walk  or  wearisome  journey,  more  than 
the  customary  degree  of  curvature  is  noticed,  while 
if  the  patient  is  not  tired  and  is  sustained  by  good 
sleep  and  digestion,  the  general  well-being  finds  ex- 


244  GROWTH  AND  DEFORMITY. 

pression  not  only  in  the  face  but  also  in  less  curva- 
ture and  rotation.  From  this  observation-  may  be 
derived  the  practical  suggestion  that  throughout  the 
growing  period  overexertion  should  be  avoided. 
The  child  should  not  be  told  to  "  sit  up  straight,"  but 
to  lie  down.  Moderation  should  govern  the  daily 
routine,  the  pastimes,  and  all  the  duties,  mental  and 
physical,  of  child  life  at  home  and  at  school. 

Sequence  of  Causes  of  Rotating  Curvature.— From 
this  review  of  clinical  phenomena  a  probable  se- 
quence of  the  causes  of  rotating  curvature  may  be 
formulated  in  these  words:  The  diminution  of  the 
cavity  of  the  chest  is  caused  by  the  rotation;  the 
rotation  in  caused:  (i)  by  an  unequal  lateral  dis- 
placement of  the  anterior  and  posterior  sections  of 
the  spinal  column;  and  (2)  by  the  curvature;  the 
curvature  is  caused  by  a  failure  of  the  muscles  to 
hold  the  column  erect  under  its  natural  burden ;  the 
failure  of  muscular  action  is  caused  by  defective  in- 
nervation, the  cause  of  which  is  as  yet  conjectural. 


INDEX. 


PAGE 

Abduction,  adduction,  and  flexion  measured  by  goniometer  .     .       168,169 

Abduction  an  early  sign  of  hip  disease 143 

Abduction  and  apparent  lengthening 117,161,162,165-167 

Abduction  desirable  after  hip  disease 161 

Abnormal  and  normal  rhythm,  diagrams  of 185,  186 

Abnormal  rhythm  an  early  sign  of  hip  disease 142,  t 80 

Abnormal  rhythm  producing  deformity  and  lameness  .     .  176,  177,  179,  185 
Abnormal  rhythm  unconsciously  adopted  to  secure  protection    .     .     .     177 

Abscess  and  contraction,  flexion  produced  by  psoas 213 

Abscess  of  uncertain  origin 214,  215 

Abscess,  scar  following  desiccation  of 133 

Abscess  simulating  hernia 214 

Abscesses  and  visceral  degeneration 139 

Abscesses,  cold 131-134,  214 

Abscesses,  doubtful  significance  of 139 

Abscesses,  spontaneous  opening  of 131, 132,  214 

Abscesses  treated  by  intelligent  expectation 137-139,215 

Absorption  of  abscesses 132,  133,  226 

Acquirement  of  correct  rhythm  by  instruction  and  military  drill   .     187,  188 
Acquirement  of  correct  rhythm  favored  by  growth   ....     180,  186,  187 

Activity  out  of  doors  secured  by  mechanical  treatment 70 

Adams  (London,  1820-iqoo),  Mr.  William 73i  113 

Adduction  and  apparent  shortening       ....  161,  162,  165-167,  170,  171 

Adduction  and  flexion  illustrated  by  jointed  dolls 163,  164 

Adduction  deporable  after  hip  disease 161 

Adduction  producing  lateral  curve  of  spine 171 

Adhesive  plaster  applied  to  untwist  anterior  part  of  foot 13 

Adhesive  plaster  in  treatment  of  club-foot 6-8,  12-14 

Adhesive  plaster  made  from  India-rubber  and  other  tropical  gums  by  Eyre 

(1848)  and  Martin  (1877) 75 

Adhesive  plaster  prehension  an  American  invention 92 

Adhesive  plaster  so  applied  as  to  avoid  dermatitis 113,114 

24s 


246  INDEX. 

PAGE 

Adhesive  plaster  to  prevent  rust 11,36 

Adhesive  plaster  traction  in  hip  disease 113,114 

Adhesive  plaster  traction  used  in  fractures  by  Gross  and  Crosby .     .    89,  90 
Adhesive  plaster  traction  used  in  hip  disease  by  Davis  and  Sayre    .     .      90 

Adhesive  plaster  used  in  club-foot  by  Cheselden  and  Gross 8 

Advanced  hip  disease,  three  unmistakable  signs  of 145,146 

Advantage  of  long  leverage  at  knee-joint 77,80,102,176 

Adverse  lever  at  ankle-joint 44 

Aged,  Pott's  disease  in  the 191 

Ailments  of  feet,  minor 31,  32 

Air  pillow  and  recumbency  in  lateral  curvature 240 

American  hip  splint,  the ■ 91,  92 

Amputation  and  exsection,  Fergusson  on 67 

Amputation  for  infantile  paralysis 35 

Amputation  in  hammer  toes 31 

Amputation  in  white  swelling  of  knee 82,  83,  137 

Amputation  of  anterior  part  of  foot  by  American  aborigines     ....    40 

Amputation  of  knee  in  Hilton's  case  of  hip  disease 100,  loi 

Anaemia  appHed  to  check  growth  of  longer  limb 182 

Analogy  in  fracture  and  hip  disease 106 

Andrews  (Cliicago,  1824-1904),  Dr.  Edmund 127 

Andry  (de  Boisregard,  1658-1742),  Nicolas 2 

Aneurj'smal  varix,  hyperaemia  and  lengthening  produced  by      ....  182 

Angular  curvature  an  incorrect  but  convenient  term 192,  193 

Angular  projection  a  demonstration  of  Pott's  disease 189,  197 

Ankle  a  corner  around  which  tendons  of  leg  pass 30 

Ankle  constriction  a  cause  of  flat-foot 29, 30 

Ankle  disease.  Dr.  Schapp's  case  of 86 

Ankle  disease  protected  by  wearing  a  peg-leg 86 

Ankle  disease  treated  on  expectant  plan  by  Dr.  Gibney 86 

Ankle-joint,  adverse  lever  at 44 

Ankylosis  in  white  swelling  of  knee,  fear  of 75 

Ankylosis  not  caused  but  prevented  by  fixation 68-70,  107 

Ankylosis  of  shoulder  and  of  hip,  vicarious  mobihty  in  ...     .     125,  161 

Ankylosis  prevented  by  subduing  inflammation 68-70,  107 

Anterior  muscles  of  thigh,  counter-pressure  in  paralysis  of    ....    35,  36 
Anterior  muscles  of  thigh,  hyperextension  of  knee  in  paralysis  of  .     .     .     35 

Antero-posterior  pressure  applied  to  oppose  rotation 237,  238 

Antero-posterior  pressure  in  lateral  curvature  advocated  by  Lee    .     .     .  237 

Apparatus  improved  by  introduction  of  Bessemer  steel 3 

Apparatus  not  requiring  cushions,  pads,  and  wadding 54 


INDEX.  247 

PAGE 

Apparent  and  real  or  structural  shortening 147,  170,  171,  180 

Apparent  lengthening  and  abduction T17,  161,  162,  165-167 

Apparent  shortening  and  adduction      ....   161,162,165-167,170,171 

Arrest  of  function,  inflammation  subdued  by 68,  74 

Artificial  limb,  ischiatic  crutch  used  as  an 127,  128 

Artificial  limb  supporting  weight  on  ischium 126 

Asymmetrical  walking  promoting  deformity 176,177,179 

Audible  suspiration  by  cadaver  after  suspension 242 

Average  life  of  pathological  doctrine,  Adams  on 73 

Axillary  and  ischiatic  support  compared 127 

Axis  of  head  displaced  in  cervical  Pott's  disease 194-196 

Axis,  rotation  of  vertebra  on  central,  peripheral,  and  remote  .     .     .      219-221 

Bad  position  in  hip  disease,  cause  of 173,174 

Ball-and-socket  joint  depending  on  muscles  for  stability 143 

"Bang"  stroke,  nails  to  be  cut  by 32 

Bartow  (Buffalo,  N.  Y.),  Dr.  Bernard 66 

Batchelder  (New  York,  1784-1868),  Dr.  John  Putnam 90 

Bauer  (New  York  and  St.  Louis,  1814-98),  Dr.  Louis 90,  99 

Bed  by  ischiatic  crutch,  affected  limb  practically  put  to     .     .     .     150,  201 

Bell  (Edinburgh,  1 775-1842),  Mr.  Charles 98,  loi,  200 

Bessemer  steel  increasing  efficiency  of  mechanical  treatment      ....       3 

Bicycle  riding  and  protection 126 

Bimanual  palpation  of  chest  in  diagnosis  of  rotation 227 

Blanchard  (Chicago),  Dr.  Wallace 81 

Blandin  (Paris,  1 798-1849),  Phillippe  Frederic 103 

Bodily  weight  affecting  treatment  of  club-foot 7-9,  14-17,  22 

Bonnet  (Lyon,  1802-58),  Amedee 102,  106 

Bow-legs  and  knock-knee  corrected  more  easily  in  recumbency.  .  .  79,  80 
Bow-legs  and  knock -knee  treated  by  pressure  and  counter-pressure  .  .  80 
Bow-legs  and  knock-knee,  growth  affecting  treatment  of     .....     79 

Boy  wearing  hip  splint  thought  he  was  "sitting  down" 113 

Boy's  ruse  to  escape  painful  examination 151 

Brace  likened  to  outside  skeleton 54,  207 

Braces  in  treatment  of  lateral  curvature,  question  of       ....     237,  238 

Bradford  (Boston),  Dr.  Edward  Hickling      . 16,  202 

Brake  promoting  fixation  by  hip  splint 105 

BrzjeMewi /orce  likely  to  promote  tuberculous  action 124 

Broca  (Paris,  1824-80),  Pierre  Paul 90,182 

Brodie  (London,  1 783-1862),  Mr.  Benjamin  Collins     ....  75,90,99, 

103,  106,  126,  226 


248  INDEX. 

PAGE 

Bronson  (New  York,  1827-97),  Dr.  John  Oscar 9° 

Buck  (New  York,  1807-77),  D''-  Gurdon        90,  105 

Bucket  release  and  lever  release 38,  39 

"  Buck's  extension  "  producing  fixation 105 

Cadaver  making  audible  suspiration  after  suspension 242 

Calcaneus  rarely  congenital,  talipes 40 

Calcaneus,  weight  transferred  from  toe  to  upper  part  of  leg  in   .     .     47,  49 

Callus  indicating  relapse  to  varus 15 

Caries  and  shortening  caused  by  overexertion  after  hip  disease  .     .     .     129 

Caries  of  sternum  producing  anterior  projection 215,  216 

Cause  of  bad  position  in  hip  disease 173,  174 

Cause  of  rotation  demonstrated  by  preparation  of  vertebral  column  221-223 

Cause  of  rotation  recognized  by  Rogers-Harrison 234 

Causes  of  lateral  curvature,  sequence  of 244 

Centre  of  gravity  of  body  in  relation  to  joint  diseases  ....      100,  loi 
Certain  recovery  from  tuberculous  joint  disease     ......    67,  68,  72 

Cervical  Pott's  disease,  crepitus  in 196 

Cervical  Pott's  disease,  horizontal  vision  by  extension  of  head  in      .  194,  195 

Cervical  Pott's  disease  illustrated  in  Young's  treatise 196 

Cervical  Pott's  disease,  forward  displacement  of  axis  of  head  in   .  194-196 

Chance  (London,  1807-95),  Mr.  Edward  John 103 

Chapman  (Monte  Vista,  Colorado),  Dr.  Norman  Hyde 126 

Character  of  pain  of  hip  disease 104 

Charcot's  knee  relieved  by  prosthetic  apparatus 53 

Charring  effect  of  infiamation  in  a  joint 69 

Cheselden  (London,  1688-1752),  Mr.  William 8 

Chest  and  abdomen  bisected  by  vertebral  column,  cavity  of      .     .     .     .     218 

Chest  expansion,  rotation  opposed  by 243 

Chest  in  diagnosis  of  rotation,  bimanual  palpation  of 227 

Childhood  tolerating  inconvenience  of  mechanical  treatment  .     55,56,  63,  72 

Circle  in  joint  disease,  vicious 93 

Clinical  features  in  Pott's  disease,  unexpected 197 

Clinical  observations  determining  treatment  of  lateral  curvature    .     .     238 

Closure  of  sinuses,  effect  of  temporary 141 

Club-feet  useful  in  locomotion,  uncorrected 16 

Club-foot  affected  by  weight  of  body 7-9,  14-17,  22 

Club-foot  at  home,  management  of 15 

Club-foot  brace,  key  to  application  of 7 

Club-foot,  division  of  tendo  Achillis  in 18 

Club-foot,  flexible 10 


INDEX.  249 

PAGE 

Club-foot,  forcible  correction  of 26 

Club-foot,  growth  and  weight  of  body  in  treatment  of  spastic  ....       16 

Club-foot,  mechanical  details  of  treatment  of 6,  7,  10-13 

Club-foot,  neglected,  relapsed,  and  inveterate 16 

Club-foot,  prosthetic  brace  for 17 

Club-foot  requiring  crutches  or  ischiatic  support 17 

Club-foot  requiring  operation,  inveterate 16 

Club-foot  treated  by  continuous  leverage 16,  17 

Club-foot  treated  by  pressure  and  counter-pressure 5,  6,  11 

Club-foot  treated  with  adhesive  plaster 6-8,  12-14 

Club-foot  treated  with  adhesive  plaster  by  Cheselden  and  Gross  ...         8 

Club-foot  treated  with  plaster  of  Paris 5 

Club-foot,  weight  of  body  transferred  from  toe  to  upper  part  of  leg  in       12 

Coates  (Philadelphia,  1797-1881),  Dr.  Benjamin  Horner 102 

Cold  abscesses 131— 134,  214 

Colles'  fracture,  mechanical  disadvantages  in  treatment  of     ...     .     102 

Comfort  dictating  position  of  limb  in  hip  disease 173,174 

Comparative  value  of  traction  and  protection  in  hip  disease   .     .     .     .     122 

Comparison 'of  axillary  and  ischiatic  support 127 

Comparison  of  hip  disease  and  fracture 106 

Comparison  of  joint  disease  and  fracture  by  David  de  Rouen    .     .     .     106 

Comparison  of  the  two  sides  important  in  diagnosis 144,  145 

Compensatory  curvature  and  compensatory  rotation  .     .     .       223,  224,  234 

Composite  sensation  of  kneeHng  and  standing 47 

Composite  sensation  of  sitting  and  standing 112,  113 

Condensation  of  soft  parts  a  diagnostic  sign  of  hip  disease 145 

Congenital  club-foot,  details  of  treatment  of 6,  7,  10-13 

Congenital  club-foot,  juvenile  growth  aiding  reduction  of  ....     .       13 

Congenital  club-foot  promptly  treated  by  Willard 5 

Congenital  dislocation  of  hip,  equine  foot  in  single 148 

Congenital  dislocation  of  hip  not  disabling 147,  148 

Congenital  dislocation  marked  by  lordosis 193,  194 

Congenital  dislocation,  "sailor  gait"  in 148 

Congenital  talipes  calcaneus  rare 40 

Conservative  surgery  of  present  day 67 

Constriction  of  ankle  a  cause  of  flat-foot 20,  30 

Continuous  leverage  in  club-foot 16,  17 

Convenience  dictating  position  of  limb  in  hip  disease     .     .     .173,  174,  176 

Cook  (Hartford,  Conn.),  Dr.  Ansel  Granville 11 

Cooper  (San  Francisco,  1822-62),  Dr.  Elias  Samuel 103 

Corner  of  ankle  turned  by  tendons  of  leg  muscles 30 


250  INDEX. 

PAGE 

Corns 31 

Correct  rhythm  acquired  by  instruction  and  military  drill  .     .     .       187,  188 

Correct  rhythm  easily  acquired  during  growth 180,  186,  187 

Correction  of  congenital  club-foot,  juvenile  growth  facilitating   ...       13 
Correction  of  deformity  of  hip  disease,  unconscious       .     .     .     .       178,  179 

Correction  of  hammer  toes  facilitated  by  growth 32 

Correlation  of  traction  and  fixation 102,  104 

Costal  kyphosis  in  extreme  lateral  curvature 236 

Counting  time  in  acquirement  of  normal  rhythm 187 

Coxa  vara,  removing  weight  of  body  in 148 

Coxa  vara  requiring  osteotomy 148 

Crabs  and  .lobsters  presenting  outside  skeletons 54 

Crepitus  in  cervical  Pott's  disease 196 

Crooked  rod  straightened  by  pressure  and  counter-pressure     .     .     .     .     176 

Crooked  rod  straightened  by  traction  and  counter-traction 175 

Crosby  (Manchester,  N.  H.,  1794-1874),  Dr.  Josiah 89,  90 

Crustaceans  presenting  outside  skeletons 207 

Crutch,  ischiatic iii,  120,  121 

Crutches  in  club-foot 17 

Crutches  in  joint  disease,  Brodie  on  use  of 126 

Cup  and  ball  illustration  of  short  leverage 102 

Cured,  hip  disease  managed  rather  than 89 

Curvatiire  and  rotation,  compensating 223,  224,  234 

Curvature  and  rotation  inseparable,  spinal 223 

Curvature  not  reduced  by  pressure  on  ribs 238 

Curvature  of  bodies  coincident  with  normal  position  of  processes  .       219,  225 

Curvature  reduced  by  factitious  lengthening  of  short  limb 181 

Curved  line  of  beauty  in  scoliosis 235 

Cushions,  pads,  and  wadding  not  necessary  in  apparatus 54 

Dancing  lessons  in  acquirement  of  normal  rhythm 187 

Date  of  diagnosis  affecting  prognosis  in  joint  disease 70,149 

David  (de  Rouen,  1737-84),  Jean  Pierre 106 

Davis  (New  York,  1807-96),  Dr.  Henrj'Gassett  .     .     .     .       90,91,172,242 
Definition  of  intelligent  expectation  in  treatment  of  joint  disease    .     .       68 

Definition  of  Hmping,  or  lameness 184 

Definition  of  orthopaedic  surgery,  Andry's 2 

Definition  of  rest  in  treatment  of  joint  disease 68 

Deformities,  growth  a  factor  in  paralytic 5ij  52 

Deformities,  growth  affecting  the  treatment  of  rachitic 79 

Deformity  of  hip  disease,  growth  favoring  reduction  of  ...     .       159,  180 


INDEX.  251 

PAGE 

Deformity  of  hip  disease  illustrated  by  Marsh's  diagrams  .     .     .     162 

Deformity  of  hip  disease  illustrated  by  manikins  and  silhouettes    .  163-167 

Deformity  of  hip  disease  reduced  by  Ridlon 172 

Deformity  of  hip  disease,  unconscious  correction  of 178,179 

Deformity  of  joints,  juvenile  growth  a  factor  in  prevention  of    .     .     .       72 
Deformity  of  lateral  curvature  less  in  recumbency  and  suspension,    239-241 

Deformity  reduced  by  w^eight  and  pulley 117,172 

Deformity,  traction  and  counter-traction  in  reduction  of  extreme    .     .     175 

Demonstration  in  orthopaedic  practice,  physical 63,161 

Deplorable  effects  of  dorsal  Pott's  disease 199,  201 

Deportment  in  diagnosis  of  Pott's  disease 197 

Derivation  of  orthopaedic  .     .         v 

Dermatitis  prevented  by  alternate  application  of  adhesive  strips  .       113,  114 

Desault  (Paris,  1749-95),  Peter  Joseph 99>  i°7 

Description  of  hip  limp 171 

Descriptionof  rotation  by  Dods  in  1824 217 

Desiccation  of  abscess  foUow^ed  by  a  scar 133 

Details  of  application  of  hip  splint  in  third  stage 11 5-1 17 

Details  of  mechanical  treatment  of  Pott's  disease 206-209 

Details  of  treatment  of  congenital  club-foot 6,7,10-13 

Detmold  (New  York,  1808-94),  Dr.  WiUiam 20 

Diagnosis  of  cervical  Pott's  disease  illustrated  by  Young 196 

Diagnosis  of  Irip  disease  by  Wilham  Ross 149 

Diagnosis  of  rotation  by  bimanual  palpation  of  chest 227 

Diagnosis  of  tumor  in  Gideon  Mantell's  case,  mistaken 226 

Diagnosis  of  white  swelling  of  knee  by  Romaine 82 

Diagnostic  sign  of  hip  disease,  Steele's 145 

Diagonal  palpation  of  chest,  diagnosis  of  rotation  by 227 

Diagrams  of  normal  and  abnormal  rhythm 185,186 

Diet  in  hip  disease 118,  17S 

Difficulty  of  direct  mechanical  reduction  in  hip  disease  ....       174-176 

Difficulty  of  fixing  hip-joint.  Bell  on 98,  99,   loi,  200 

Disadvantage  of  short  leverage  at  hip-joint loi,  102,  176 

Disadvantages  of  human  foot,  mechanical 26,  27 

Discontinuing  treatment  of  hip  disease 128,  129 

Discovery  of  motion  in  hip  disease ,     .       146,  147 

Discovery  of  reflex  action  in  hip  disease 143,  144 

Disease  of  wrist,  elbow,  and  shoulder 124,  125 

Dislocation  of  hip,  congenital 147,  148,  180,  193,  194 

Dispensary,  Schapps  on  equipment  of  orthopaedic 59,  60 

Displacement  of  fixative  brace  prevented  by  special  device .....       79 


252  INDEX. 

PAGE 

Division  of  tendo  Achillis,  Hibbs  on   . 46 

Division  of  tendo  Achillis  in  club-foot o     .     .     .       18 

Dods  (London),  Dr.  Andrew  217 

Dods'  recognition  of  rotation    ...  217 

Dolls  illustrating  flexion  and  adduction,  jointed     ......       163,164 

Doorway  bar  for  suspension  in  lateral  curvatxire 241 

Dormant  muscular  power  developed  by  apparatus 60,  61 

Dow  splint,  Dr.  Taylor's .     127 

Drainage  of  region  of  initial  foci  in  hip  disease 139,  140 

Drill  and  instruction  in  acquirement  of  correct  rhythm  ....       187,  188 

Dundreary's  witticism  based  on  philosophy  and  humor 100 

Duplicate  braces 55 

Duration  of  treatment  of  hip  disease 93,  138 

Duration  of  treatment  of  tuberculous  joints 7i>72 

Early  diagnosis  in  joint  disease,  Taylor  on  importance  of    ...     .       70 

Early  diagnosis  in  Pott's  disease 89, 90,  196,  197 

Early  diagnosis  of  white  swelling  of  knee 81,  82 

Early  sign  of  hip  disease,  abnormal  rhythm  an 142,180 

Early  stage  of  infantile    paralysis,  recumbency    and   graduated   ex- 

.  ercises  in 34 

Early  treatment  of  congenital  club-foot,  Willard  on 5 

Elbow  disease 123,  124 

Elongation  of  tendo  Achillis  inevitable  in  paralysis 40 

Environment  affecting  course  of  hip  disease,  mechanical       .     .     .      87,  88 
Environment,  recovery  of  diseased   knee  hastened  by  improved  me- 
chanical       74 

Environment,  tuberculous  action  influenced  by  mechanical     .     .     .    62,  123 
Epiphyseal  hyperasmia  causing  lengthening  in  knee  disease  ....        84 

Equilibrium  preserved  by  lordosis  in  Pott's  disease 193,  194 

Equine  foot  favored  by  short  tendo  Achillis 184 

Equine  foot  in  single  congenital  dislocation  of  hip 148 

Equine  foot  neutralizing  structural  shortening 154,  183-185 

Equipment  of  orthopaedic  laboratory 59,  60 

Erect  position  in  infantile  paralysis,  postponement  of 34 

Exact  science  in  orthopaedic  practice,  methods  of  precision  and,  63,  73,  163 

E.xamination,  boy's  ruse  to  escape  painful 151 

Exanthemata,  deportment  of  sinuses  in 141 

Exempt  from  tuberculous  joints,  upper  extremities  comparatively  .     70,  123 

Expansion  of  chest,  rotation  opposed  by 243 

Expectant  plan  in  ankle  disease,  Gibney  on  . 86 


INDEX.  253 

PAGE 

Expectant  treatment  of  tuberculous  joint  disease 4,  67,  68 

Expectation  in  abscesses 137-139,  215 

Expectation  in  third  stage  of  hip  disease 159 

Expectation  in  treatment  of  joint  disease,  definition  of 68 

Expectation  in  tuberculous  joint  disease 67,  68 

Exsection  and  amputation,  Fergusson  on 67 

Extension  of  head,  horizontal  vision  in  Pott's  disease  preserved  by  .     194,  195 

Extension  shoe 183,  185 

Extension,  traction  formerly  called 89 

Extreme  lateral  curvature  producing  costal  kyphosis 236 

Eyre  (Derby,  England),  Mr.  Douglas  Fox 75 

Falling  and  perpetual  recovery  in  locomotion,  perpetual      .     .     .      41,  51 

Fear  of  ankylosis 75 

Fear  of  wounding  tendons,  subcutaneous  tenotomy  postponed  by     .     .  3 

Feeding  in  hip  disease 118,178 

Feet  in  club-foot  and  hip  disease,  outlines  of 22,155,156,158 

Feet,  minor  ailments  of 31,  32 

Fergusson  (London,  1808-77),  ^r.  William 67 

Fever,  synovitis  of  hip-joint  after  typhoid 148 

Fibula,  mistaken  diagnosis  of  fracture  of 145 

Figure  in  Pott's  disease,  growth  facilitating  improvement  of  .     .       204,  205 

Finnell  (New  York,  1826-90),  Dr.  Thomas  Constantine 90 

Fixation  and  protection  in  white  swelling  of  knee 74>  85 

Fixation  and  release  of  jointed  brace  for  leg 37~39 

Fixation  and  traction,  correlation  of 102,  104 

Fixation  by  weight  and  pulley  or  hip  splint  demonstrated  .     .     .       104,  105 

Fixation,  healthy  joint  not  injured  by 69,  70 

Fixation,  inflammation  subdued  by        69,  70,  107 

Fixation  initiated  by  reflex  contraction  and  confirmed  by  ankylosis  .     .     171 

Fixation  of  hip-joint,  Bell  on 98,99,101,200 

Fixation  of  knee  by  pressure  and  counter-pressure 76 

Fixation  preventing  not  causing  ankylosis    .......       68-70,  107 

Fixation  produced  by  "Buck's  extension" 105 

Fixation  with  hip  splint  promoted  by  brake 105,  106 

Fixative  brace,  flexion  of  knee  corrected  by 77 

Fixative  brace  to  knee,  key  to  application  of 78 

Flat-feet  benefited  by  throwing  weight  of  body  on  heel 30 

Flat-feet  requiring  rest 29 

Flat-foot  caused  by  constriction  of  ankle 29,  30 

Flat-foot  caused  by  growth  and  increasing  weight 28 


254  INDEX. 


PAGE 

Flexible  club-foot lo 

Flexion  and  adduction  illustrated  by  jointed  dolls 163,164 

Flexion  and  extension  of  spine,  rotation  independent  of    .     •     .       232,  233 

Flexion  of  foot,  normal 21 

Flexion  of  hip  disease  causing  lordosis 166,  167,  171,  194 

Flexion  of  knee  after  operation,  Townsend  on 83 

Flexion  of  knee  corrected  by  fixative  brace 77 

Flexion  of  knee  measured  with  goniometer 86 

Flexion  produced  by  psoas  abscess  and  contraction 213 

Foci  drained  in  hip  disease,  region  of  initial 139,  140 

Foot,  growth  promoting  recovery  of  deformed 62 

Foot  measured  with  goniometer,  flexion  of 21 

Foot,  normal  flexion  of 21 

Foot  straight,  stamping  a 10,  13 

Forced  extension  and  plastic  dressings  in  Pott's  disease  ....       208,  209 

Forcible  correction  in  Pott's  disease 206 

Forcible  correction  of  club-foot 26 

Ford  (London,  1746-1809),  Mr.  Edward 106 

Fracture  and  hip  disease  compared 106 

Fracture  and  joint  disease  compared  by  David  de  Rouen 106 

Fracture  and  joint  disease,  paradox  in  treatment  of 106 

Fracture  of  longer  bone  to  neutralize  structural  shortening 181 

Fracture  treated  with  adhesive  plaster  by  Gross  and  Crosby     .     .     .      89,  90 
Frame  for  treatment  of  Pott's  disease,  Bradford's  portable    ....     202 

Freiberg  (Cincinnati),  Dr.  Albert  Henry 182 

French  (Portland,  Maine,  1837-97),  Dr.  George  Franklin 242 

Friedreich's  disease,  talipes  of 53 

Function,  inflammation  subdued  by  arrest  of 68,  74 

Function  of  muscular  system  of  joint,  twofold 100 

Functional  ability  facilitated  by  growth,  acquisition  of 160 

Functional  result  after  hip  disease,  Hilton's  illustration  of 159 

Functional  result  after  third  stage  of  hip  disease 158-160 

Gait,  protection  by  ischiatic  crutch  promoting  symmetrical  .     .       177-179 

Gait,  rhythm  an  important  element  of 118,  187 

Garfield,  rotation  of  spine  in  case  of  President 218,219 

Gastralgia  in  Pott's  disease 197 

Gestation,  lordosis  of .     194 

Gibney  (New  York),  Dr.  Homer 193 

Gibney  (New  York),  Dr.  Virgil  Pendleton 78,86,97 

Goldthwait  (Boston),  Dr.  Joel  Ernest 194 


INDEX.  255 

PAGE 

Goniometer  in  measurement  of  abduction,  adduction,  and  flexion     168,  169 

Goniometer  in  measurement  of  flexion  of  foot 21 

Goniometer  in  measurement  of  flexion  of  knee 86 

Goniometer  in  measurement  of   motion  in  hip  disease     .     .     .     146, 147 

Graceful  sinuosity  imparted  to  sigmoid  curve  by  rotation 224 

Graduated    exercises    and    recumbency   in    early   stage  of  infantile 

paralysis 34 

Gross  (Philadelphia,  1805-84),  Dr.  Samuel  David 8,  89 

Growth  a  factor  in  congenital  club-foot 5,8,13,22,26,62 

Growth  a  factor  in  prevention  of  deformity  after  joint  disease  ....       72 

Growth  a  factor  in  recovery i 

Growth  a  factor  in  removal  of  structural  shortening 182 

Growth,  acquirement  of  correct  rhythm  facilitated  by   .     .     .    180,  186,  187 

Growth  affecting  results  of  hip  disease 159,  180 

Growth  affecting  treatment  of  paralytic  and  rachitic  deformities  .     51,  52,  79 

Growth  aiding  development  of  paralyzed  muscles 60,  61 

Growth  and  increasing  weight  causes  of  flat-foot,  rapid 28 

Growth  and  recumbency  in  treatment  of  lateral  curvature      ....     239 

Growth,  correction  of  hammer  toes  facilitated  by 32 

Growth  dictating  changes  in  apparatus i3i  14,  206 

Growth  favoring  effect  of  rest  and  suspension  in  lateral  curvature     .  243,  244 

Growth  favoring  recovery  from  Pott's  disease 191 

Growth  favoring  reduction  of  deformity  in  hip  disease  ....  159,  180 
Growth,  improvement  of  figure  in  Pott's  disease  facilitated  by  .  .  204,205 
Growth  in  Pott's  disease  encouraged  by  mechanical  treatment   .     .     .     210 

Growth  in  spondylitics,  H.  L.  Taylor  on 210 

Growth  in  treatment  of  spastic  club-foot 16 

Growth,  introduction  of  functional  ability  favored  by 160 

Growth,  natural  resistance  to  disease  aided  by 67 

Growth  of  bone  and  hypersemia,  Broca  and  Helferich  on, 182 

Growth  promoting  recovery  from  Joint  disease 67,  72 

Growth,  recognition  of  varying  rates  of 2 

Growth,  repair  the  repetition  of     .         i 

Growth,  rest,  and  repair,  Hilton  on 1,4 

Growth,  treatment  to  be  more  urgent  in  periods  of  rapid 2 

Gum  in  place  of  oxide  of  zinc  in  adhesive  plaster 75 

Gymnasium,  spinal  rotation  seen  in 225 

Habitual  traumatism,  resolution  of  inflammation  prevented  by      .     .     70 

Hammer  toes,  amputation  in 31 

Hammer  toes,  growth  facihtating  correction  of        32 


256  INDEX. 

^  PAGE 

Hancock  (London,  1809-80),  Mr.  Henry       114,  115 

Hayward  (Boston,  1791-1863),  Dr.  George 89 

Head  displaced  forward  in  cervical  Pott's  disease,  axis  of    .     .     .      194-196 

Head  extended  to  preserve  horizontal  vision 194-196 

Healthy  joint  not  injured  by  fixation 69,  70 

Heel  in  diagnosis  of  hip  disease,  pounding  the 151 

Helferich  (Greifswald),  Heinrich 182 

Hernia  simulated  by  abscess 214 

Hibbs  (New  York),  Dr.  Russell  Aubra 46 

High  sole  and  low  sale  in  actual  shortening 183 

High  sole  for  well  foot  with  protective  apparatus 126 

Hilton  (London,  1804-78),  Mr.  John •     i,  4,  100,  loi,  159 

Hip  and  knee  deformities  reduced  by  pressure  and  counter-pressure  175,  176 

Hip  disease,  abnormal  rhythm  an  early  sign  of 142,  180 

Hip  disease  and  fracture  compared 106 

Hip  disease  and  knee  disease,  pendent  limb  in 82,122 

Hip  disease,  "apparent"  deformities  in  . 163 

Hip  disease,  character  of  pain  of         104 

Hip  disease,  condensation  of  soft  parts  a  diagnostic  sign  of  .  .  .  .  145 
Hip  disease  cured  by  amputation  of  knee,  Hilton's  case  of  .  .  100,  loi 
Hip  disease  described  by  Hancock,  patient  third  stage  of      .     .       114,  115 

Hip  disease,  diet  in 118,  178 

Hip  disease,  discontinuing  treatment  of  . 128,  129 

Hip  disease,  discovery  of  motion  in 146,  147 

Hip  disease,  discovery  of  reflex  muscular  action  in      .     .     .     .     .•      143,144 

Hip  disease,  duration  of  treatment  of .        93,  138 

Hip  disease,  effect  of  reflex  muscular  action  in       .       144,  149,  150,  171,  172 

Hip  disease,  historical  notes  on  treatment  of 88 

Hip  disease  illustrated  by  manikins  and  silhouettes,  deformity  of  163-167 
Hip  disease  illustrated  by  Marsh's  diagrams,  deformity  of    ...     .     162 

Hip  disease  managed  rather  than  cured 89 

Hip  disease,  mathematical  appreciation  of  results  of 160-169 

Hip  disease,  mechanical  environment  affecting  course  of     ...     .     87,  88 

Hip  disease,  motion  less  important  than  position  in 161 

Hip  disease,  natural  repair  in 87,  138 

Hip  disease,  pain  in  knee  in 142,  143,  149,  191 

Hip  disease  promptly  recognized  by  Ross 149 

Hip  disease,  recovery  insured  by  mechanical  treatment  of 138 

Hip  disease,  Steele's  diagnostic  sign  of 145 

Hip  disease  treated  with  weight  and  pulley  by  Brodie 90,  99 

Hip  disease,  unconscious  correction  of  deformity  of 178,  179 


INDEX.  257 

PAGE 

Hip  disease,  unmistakable  signs  of  advanced 145,  146 

Hip  disease,  weight  and  pulley  in  third  stage  of 117 

Hip-joint,  Bell  on  difhculty  of  fixing 98,99,  101,200 

Hip-joint,  disadvantage  of  short  leverage  at loi,  102,  176 

Hip-joint,  position  not  determined  by  morbid  anatomy  of 174 

Hip  limp,  description  of 171 

Hip  splint,  Andrews' 127 

Hip  splint  at  home,  rule  for  management  of 119,120 

Hip  splint,  description  of 107-109 

Hip  splint  in  third  stage,  details  of  application  of 115-117 

Hip  splint,  length  of  perineal  strap  key  to  use  of 109,110,119 

Hip  splint  or  weight  and  pulley,  fixation  produced  by    ...     .       104,  105 

Hip  splint  thought  he  was  "sitting  down,"  boy  wearing 113 

Hip,  vicarious  mobility  in  ankylosis  of 161 

Hip,  weight  of  body  to  be  removed  from  diseased 87 

Historical  notes  on  treatment  of  hip  disease 88 

Holcombe  (New  York,  1828-1904),  Dr.  William  Frederick    .     ^     .     .       90 

Holmes  (Boston,  1809-94),  Dr.  Oliver  Wendell 41,  5° 

Home  management  of  club-foot  brace 15 

Home  management  of  white  swelling  of  knee 8^,86 

Home,  rule  for  management  of  hip  splint  at 119,  120 

Horizontalvisionpreservedby  extension  of  head  in  cervical  Pott's     .   194,  195 

Horseback  riding  and  protection 126 

Horseshoe  forged  with  an  extension ' 1 1 

Horse's  lameness  concealed  by  cruel  device 184,185 

Human  foot  criticised  by  Savarin,  construction  of 27 

Human  foot,  mechanical  disadvantages  of 26,27 

"Human  wheel" 41 

Humor  and  philosophy  in  Dundreary's  witticism 100 

Hunter  (London,  1728-93),  Mr.  John 71 

Hypereemia  and  growth,  Broca  and  Helferich  on 182 

Hyperaemia  and  lengthening,  aneurysmal  varix  producing     .     .     .     .     182 

Hyperaemia  induced  in  joint  disease  by  Freiberg 182 

Hyperaemia  of  epiphysis,  lengthening  caused  by 84 

Hyperaemia  promoting  growth  of  shorter  limb 182 

Hyperextension  in  white  swelling  of  knee 77,  83-85 

Hyperextension  of  knee  by  pressure  and  coimter-pressure  .  .  .  35,77 
Hyperextension  of  knee  promoting  stabihty  in  paralysis  and  disease  35,  84 
Hyperextension  of  normal  knee 84 

Iliac  fossae,  psoas  abscess  recognized  by  palpation  of 214 

17 


258  INDEX. 

PAGE 

Ilio-ischiatic  line  to  trochanter,  relation  of       . 169 

Immovable  movable  joint 77,  172 

Importance  of  comparing  the  two  sides  in  diagnosis 144,  145 

Importance  of  mechanical  surgery,  Stephen  Smith  on 58 

Incidental  rotating,  or  lateral,  curvature 234 

Inconstant  lameness  a  sign  of  joint  disease 81,82,142 

India-rubber  used  in  adhesive  plaster  by  Eyre  and  Martin    ....       75 

Infantile  paralysis,  hyperextension  of  knee  desirable  in 35 

Infantile  paralysis  in  upper  extremities 33 

Infantile  paralysis,  postponement  of  erect  position  in 34 

Infantile  paralysis,  recumbency  and  graduated  exercises  in  early  stage  of      34 

Infantile  paralysis,  rolling  gait  of  jolly  tar  in 185 

Infantile  paralysis,  spontaneous  recovery  from 33 

Inflamed  abscesses 134-136 

Inflammation,  ankylosis  prevented  by  subduing 68-70,  107 

Inflammation  of  joint  prolonged  by  use 73 

Inflammation,  structures  of  joint  charred  by 69 

Inflammation  subdued  by  arrest  of  function 68,  74 

Inflammation  subdued  by  fixation  of  joint 69,  70,  107 

Inflammation  subdued  by  rest 68,  69,  74 

Ingrowing  nails 32 

Initial  foci  in  hip  disease,  drainage  of  region  of 139,  140 

Innutrition  and  tuberculous  joint  disease 64,  65 

In-sole,  protection  of  shoe  by  steel 12 

Intelligent  expectation  in  abscesses 137-139,215 

Intelligent  expectation  in  disease  of  wrist,  elbow,  and  shoulder   .       124,  125 

InteUigent  expectation  in  joint  disease,  definition  of 68 

Intelligent  expectation  in  third  stage  of  hip  disease 159 

Intelligent  expectation  in  tuberculous  joint  disease 4,  67,  68 

Intervertebral  pressure  by  posterior  force,  redistribution  of       .   203,  209,  237 

Inversion  of  toe  in  club-foot        15 

Inveterate  club-foot  requiring  operation 16 

Inveterate  relapsed  and  neglected  club-foot       16 

Ischiatic  and  axillary  support  compared 127 

Ischiatic  -crutch in,  120,  121 

Ischiatic  crutch,  affected  limb  practically  put  to  bed  by  .     .     .       150,  201 

Ischiatic  crutch  as  an  artificial  limb 127,  128 

Ischiatic  crutch  in  rachitic  deformities  of  legs 80 

Ischiatic  crutch  in  treatment  of  knee  disease 81 

Ischiatic  crutch  in  treatment  of  ununited  fracture 128 

"Ischiatic  crutch,"  Prince's 127 


INDEX.  259 

PAGE 

Ischiatic  support  in  club-foot 17 

Ischiatic  support,  traction  discontinued  in  favor  of 120,121 

Ischium  receiving  weight  in  artificial  limbs 126 

Jacket,  plaster-of-Paris 208 

Joint,  charring  effect  of  inflammation  on  structures  of 69 

Joint  disease  affected  by  weight  of  body 123 

Joint  disease  and  fracture,  paradox  in  treatment  of 106 

Joint  disease,  duration  of  treatment  of 71.72 

Joint  disease,  growth  promoting  recovery  from 62,  67,  72 

Joint  disease.  Hunter  on  muscular  action  in 171,172 

Joint  disease,  intelligent  expectation  in  treatment  of  tuberculous    .  4,  67,  68 
Joint  disease  less  serious  when  remote  from  centre  of  gravity  .     .       100,  loi 

Joint  disease,  neuro-muscular  element  of 171 

Joint  disease  requiring  early  diagnosis 70 

Joint  disease  tabulated  in  upper  and  lower  extremities 123 

Joint  disease  treated  by  induction  of  hyperaemia  by  Freiberg  ....     182 

Joint  disease,  vicious  circle  in    ... 93 

Joint  not  injiired  by  fixation,  healthy 69,  70 

Jointed  brace  for  leg  with  fixation  and  release 37~39 

Joints,  natural  repair  and  recovery  of  tuberculous 67 

Joints  of  lower  extremity  exposed  to  violence  in  locomotion  .  123,  124,  126 

Jolly  tar  assumed  in  infantile  paralysis,  rolling  gait  of 185 

Jury-mast  suspension  in  Pott's  disease        203,  209 

Juvenile  growth  a  factor  in  prevention  of  deformity  of  joints  ....       72 
Juvenile  grovs^th  aiding  treatment  of  congenital  club-foot 13 

Key  to  application  of  club-foot  brace 7 

Key  to  application  of  fixative  brace  to  knee 78 

Key  to  application  of  hip  splint,  length  of  perineal  strap  the     .    109,  no,  119 

Knee  corrected  by  fixative  brace,  flexion  of 77 

Knee  disease  and  hip  disease,  pendent  limb  in 82,122 

Knee  disease  attended  by  subluxation 82,  85 

Knee  disease,  flexion  followdng  operation  for 83 

Knee  disease  formerly  requiring  amputation 82,  83 

Knee  disease,  home  management  of 85,  86 

Knee  disease,  reflex  muscular  action  in 81,82 

Knee  flexion  reduced  with  plaster  of  Paris  by  Gibney 78 

Knee,  hyperextension  of  normal 84 

Knee,  hyperextension  promoting  stability  of 35,  84 

Knee  in  hip  disease,  Hilton's  case  of  amputation  of 100,  loi 


26o  INDEX. 

PAGE 

Knee  in  hip  disease,  pain  in 142,  143,  149,  191 

Knee-joint,  advantage  of  long  leverage  at 77,  80,  102,  176 

Knee-joint  fixed  by  leverage 77,  85,  176,  202,  203 

Knee,  key  to  application  of  fixative  brace  to 78 

Knee,  protection  and  fixation  in  white  swelling  of 74,  85 

Knee,  weight  of  body  to  be  removed  from  diseased 74 

Kneeling  and  standing,  composite  sensation  of 47 

Knock-knee  and  bow-leg  corrected  more  easily  in  recumbency    .     .      79,  80 

Knock -knee  and  bow-leg,  growth  affecting  treatment  of 79 

Knock-knee  and  bow-leg  treated  by  leverage 80 

Knock-knee  and  bow-leg,  weight  of  body  to  be  removed  in  ...     .      79,  80 

Krackowizer  (New  York,  1822-75),  Dr.  Ernst 90 

Kyphosis  in  extreme  lateral  curvature,  costal 236 

Kyphosis,  scoliosis,  and  lordosis 193 

Laboratory,  equipment  of  orthopaedic 59,  60 

Laced  legging  in  place  of  roller  bandage,  Taylor's 112,113 

Lameness  concealed  by  normal  rhythm 178,185 

Lameness,  definition  of , 184 

Lameness  in  horse  concealed  by  cruel  device 184,  185 

Lameness  produced  by  abnormal  rhythm 185 

Lameness  replaced  by  symmetrical  walking 186 

Landmarks  of  spine.  Whitman's 192 

V  ankylophohie 75 

Lateral  curvature,  costal  kyphosis  in  rare  cases  of 236 

Lateral  curvature  in  recumbent  child,  muscular  action  a  factor  in     .   239,  240 

Lateral  curvature,  incidental  and  typical 234,  235 

Lateral  curvature,  muscular  compression  a  cause  of    ...     .       239,  240 

Lateral  curvature  not  a  disabling  affection 235 

Lateral  curvature,  question  of  braces  in  treatment  of 237,  238 

Lateral  curvature,  sequence  of  causes  of 244 

Lateral  curvature  simulated  by  sciatica 228,  229 

Lateral  curvature  treated  by  suspension  and  rest 241,  243 

Lateral  curvature,  unrecognized  cases  of 225,  226 

Lateral  curve  in  Pott's  disease 189 

Lateral  curve  of  spine  produced  by  adduction  of  hip  disease   .     .     .     .     171 

Lead-pipe  stiffness  of  diseased  joint 172 

Leaden  sole  for  affected  foot 126 

Lee  (Philadelphia),  Dr.  Benjamin 237 

Legging  substitute  for  roller  bandage,  Taylor's  laced  .     .     .     .       112,  113 
Length  of  perineal  strap  key  to  use  of  hip  splint 109,110,119 


INDEX.  261 

PAGE 

Lengthening  in  knee  disease  produced  by  epiphyseal  hyperaemia  .  .  84 
Lengthening  of  short  limb,  curvature  reduced  by  factitious  ....  181 
Lengthening  produced  by  abduction,  apparent  .  117,  161,  162,  165-167 
Lengthening  produced  by  aneurysmal  varix  and  hyperaemia      .     .     .     182 

Leopards  and  other  animals  exhibiting  rotating  curvature 225 

Lesauvage  (Caen,  1778-1852),  Edme 99 

Lever  at  ankle-joint,  adverse ...       44 

Lever  release  and  bucket  release 38,  39 

Leverage  apphed  to  fix  knee-joint 77,85,176,202,203 

Leverage  at  hip-joint,  disadvantage  of  short loi,  102,  176 

Leverage  at  knee-joint,  advantage  of  long 77,80,176 

Leverage  illustrated  by  cup  and  ball,  short 102 

Leverage  in  treatment  of  club-foot 511,512,516,517 

Leverage  in  treatment  of  knock-knee  and  bovp-Iegs 80 

Leverage  in  treatment  of  Pott's  disease 203 

Limb  in  treatment  of  knee  disease  and  hip  disease,  pendent   .     .     .82,122 

Limping,  definition  of 184 

Listen  (London,  1794-1846),  Mr.  Robert 99,  225 

Little  (London,  1810-94),  Dr.  William  John 19.  20 

Lobster  and  crab,  outside  skeleton  of 54 

Location  of  sinuses  in  hip  disease 135,  139,  140,  153 

Locomotion  and  traumatism  inseparable 123,  124,  126 

Locomotion  impaired  by  long  tendo  Achillis 40,  46 

Locomotion,  mechanics  of 41,  50,  51,  84 

Locomotion,  perpetual  falling  and  perpetual  recovery  in      .     .     .     .     41,51 

Locomotion,  rhythm  of  human 118,  142,  148,  185-187 

Locomotion  unimpaired  by  moderately  short  tendo  Achillis  .  .  .  21,46 
Locomotor  ability  in  uncorrected  club-foot,  Bradford  and  Lovett  on  .       16 

Locomotor  ataxia,  talipes  valgus  of 53 

Long  leverage  at  knee-joint,  advantage  of 77,  80,  176 

Long  tendo  Achillis,  locomotion  impaired  by 40,  46 

Longevity  not  compromised  by  congenital  dislocation  of  hip.     .     .     .      148 

Longevity  not  compromised  by  lateral  curvature  of  spine 235 

Lordosis  caused  by  flexion  of  hip  disease 166,  167,  171,  194 

Lordosis  in  psoas  contraction,  gestation,  and  muscular  paralysis  .     .     .     194 

Lordosis  in  treatment  of  lateral  curvature 240 

Lordosis  preserving  equihbrium  in  Pott's  disease 193,  194 

Lordosis,  scoliosis,  and  kyphosis 193 

Lordosis  seen  in  opisthotonos  and  congenital  dislocation 193 

Lovett  (Boston),  Dr.  Robert  Williamson 16 

Low  sole  and  high  sole  in  actual  shortening 183 


262  INDEX. 

PAGE 

Lumbar  region,  mechanical  support  ineffective  in  Pott's  disease  of  .     .     200 

Macnamara  (London,  1834-99),  Mr.  Charles  Nottidge 66 

Malignant  disease  of  vertebrae,  Myers  on  diagnosis  of 199 

Management  of  hip  splint  at  home,  rule  for 119,120 

Management  of  spinal  brace,  rule  for 207 

Manikins  and  silhouettes,  deformity  of  hip  disease  illustrated  by .     .  163-167 

Mantell's  case,  mistaken  diagnosis  of  tumor  in  Gideon 226 

March  (Albany,  N.  Y.,  1 795-1869),  Dr.  Alden 89,  106 

Marking  time  in  acquirement  of  normal  rhythm  ........     187 

Marsh  (London),  Mr.  Howard 162 

Martin  (Paris),  Ferdinand 106 

Martin  (Boston,  1824-84),  Dr.  Henry  Austin 75 

Mathematical  appreciation  of  results  of  hip  disease 160-169 

Mathematical  certainty  in  orthopaedic  practice 161 

Mathematical  demonstration  of  strain  on  tendo  Achillis  ....  42-46 
Measurement  of  deformity  of  hip  disease  with  goniometer  .     .     .       168,169 

Measurement  of  flexion  of  foot  with  goniometer 21 

Measurement  of  flexion  of  knee  with  goniometer 86 

Measurement  of  motion  in  hip  disease  with  goniometer    .     .     .       146,  147 

Mechanical  details  of  treatment  of  club-foot 6,  7,  10-13 

Mechanical  disadvantages  in  treatment  of  Colles'  fracture     ....     102 

Mechanical  disadvantages  of  human  foot 26,  27 

Mechanical  environment  affecting  course  of  hip  disease  ....  87,  88 
Mechanical  environment,  tuberculous  action  influenced  by  .  .  .  62,123 
Mechanical  laws  in  orthopaedic  practice,  application  of  ...  .  63,  162 
Mechanical  or  operative  treatment  of  tuberculous  Joint  disease   .     .       65-67 

Mechanical  reduction  of  deformity  in  hip  disease 174-176 

Mechanical  support  not  effective  in  lumbar  Pott's  disease       ....      200 

Mechanical  surgery,  Stephen  Smith  on  importance  of 58 

Mechanical  treatment  encouraging  growth  in  Pott's  disease  ....      210 

Mechanical  treatment  of  hip  disease,  recovery  insured  by 138 

Mechanical  treatment  of  Pott's  disease,  details  of        206-209 

Mechanical  treatment  permitting  outdoor  activity 70 

Mechanical  treatment  tolerated  by  children,  inconvenience  of   55,  56,  63,  72 

Mechanics  of  locomotion 41,  50,  51,  84 

Mechanics  of  production  of  talipes  varus  and  valgus 51 

Medication  in  hip  disease 118 

Medicine  and  surgery,  new  truths  in 3 

Methods  of  precision  and  exact  science  in  orthopaedic  practice  .  63,  73,  163 
Military  drill  in  acquirement  of  correct  rhythm 186-188 


INDEX.  263 

PAGE 

Miner  (New  York,  1780-1863),  Dr.  William  W 90 

Minor  ailments  of  feet Z^^i'^ 

Misleading  tumors  caused  Vjy  rotation 225-227 

Mistaken  diagnosis  of  tumor  in  Gideon  Mantell's  case 226 

Mobility  in  ankylosis  of  shoulder  and  of  hip,  vicarious     ....  125,  161 

Modifying  quadrupedal  gait,  methods  of 11,184,185 

Moore  (Minneapolis),  Dr.  James  Edward 229 

Morbid  anatomy  of  hip-joint,  inferences  from 95~98 

Morbid  anatomy  of  hip-joint,  position  not  determined  by 174 

Motion  in  hip  disease,  discovery  of 146,  147 

Motion  in  hip  disease  less  important  than  position 161 

Motion  in  hip  disease  measured  with  goniometer 146,  147 

Movable  immovable  joint 77>  ^72 

Mural  theory  of  rotation 231 

Muscles  aided  by  growth,  development  of  paralyzed 60,  61 

Muscles  arresting  passive  motion  by  reflex  action  ....  81,  82,  143,  144 

Muscles  "  on  guard  "  in  joint  disease 172 

Muscular  action  in  hip  disease,  discovery  of  reflex 143,  144 

Muscular  action  in  hip  disease,  effect  of  reflex  .     .       144,  149,  150,  171,  172 

Muscular  action  in  joint  disease,  Hunter  on 171,172 

Muscular  compression  a  cause  of  lateral  curvature,  longitudinal .       239,  240 

Muscular  system  of  joint,  twofold  function  of 100 

Muscular  wasting  an  early  sign  of  hip  disease ...     143 

Myers(New  York),Dr.  ThaddeusHalsted 199 

Nails,  ingrowing 32 

Nails  to  be  cut  by  "  bang  "  stroke 32 

Napier  (New  York),  Dr.  Charles  Dwight 202 

"  Natural  cure  "  of  hip  disease 89 

Natural  reaction  and  consoHdation  in  Pott's  disease 205 

Natural  repair  and  recovery  in  tuberculous  joint  disease 67 

Natural  repair  in  hip  disease 87,  138 

Natural  resistance  to  disease  aided  by  growth 67 

Necrosis  of  shoulder,  Paget's  case  of  quiet 125 

Neglected  club-foot,  prosthetic  brace  for 17 

Neglected,  relapsed,  and  inveterate  club-foot 16 

Neuro-muscular  element  of  joint  disease 171 

New  truths  in  medicine  and  surgery 3 

Nil  desperandum  in  treatment  of  Pott's  disease 201 

Non-deforming  club-foot 39,  40 

Normal  and  abnormal  rhythm,  diagrams  of    ......     .       185,  186 


264  INDEX. 

PAGE 

Normal  knee,  hyperextension  of 84 

Normal  position  of  spinous  processes   coincident  with  curve  of 

bodies 219,  225 

Normal  rhythm  conceahng  lameness 178,  185 

Normal  rhythm  encouraged  by  protection  of  the  joint    .     .     .     .       177,178 
Normal  rhythm  preventing  deformity 177-179 

Objective  signs  and  subjective  symptoms 142,  162,  228 

Old  age  not  exempt  from  Pott's  disease 191 

"On  guard  "  in  joint  disease,  muscles 172 

Operations  followed  by  flexion  in  knee  disease 83 

Operative  or  mechanical  treatment  of  tuberculous  joint  disease     .     .     65-67 

Operative  removal  of  tuberculous  deposits 66 

Operative  treatment  of  inveterate  club-foot 16 

Opisthotonos  an  example  of  lordosis 193 

Orthopaedic,  derivation  of v 

Orthopaedic  laboratory,  equipment  of 59,  60 

Orthopaedic  practice,  application  of  mechanical  laws  in     .         .     .    63,  162 

Orthopaedic  practice,  mathematical  certainty  in 161 

Orthopaedic  practice,  methods  of  precision  and  exact  science  in  .63,  73,  163 

Orthopaedic  practice,  physical  demonstration  in 63,  161 

Orthopaedic  surgery,  Andry's  definition  of 2 

Orthopaedic  surgery  as  a  specialty 61 

Osteoclasis  in  rachitic  deformities,  Blanchard  on 80,  81 

Osteotomy,  deformity  of  coxa  vara  corrected  by 148 

Outlines  of  feet  in  cases  of  club-foot  and  hip  disease   .  22,  155,  156,  158 

Out-of-door  activity  secured  by  mechanical  treatment 70 

Outside  skeleton,  brace  likened  to 54,  207 

Overexertion  after  hip  disease,  caries  and  shortening  caused  by    .    129,  154 

Overuse  and  disuse  producing  deformity 170,  181 

Oxide  of  zinc  replaced  by  tropical  gums  in  adhesive  plaster 75 

Pads,  wadding,  and  cushions  seldom  necessary  in  apparatus  ....       54 

Paget  (London,  1814-99),  Mr.  James 125 

Pain  absent  in  early  hip  disease 151 

Pain  and  disability  absent  in  Pott's  disease,  local 197,  198 

Pain  in  knee  in  hip  disease 142,  143,  149,  191 

Pain  in  stomach  in  Pott's  disease 142,  191,  192,  197 

Pain  of  hip  disease,  character  of    .     -. 104 

Painful  examination,  boy's  ruse  to  escape 151 

Palpation  of  chest  for  discovery  of  rotation,  bimanual 227 


INDEX.  265 

PAGE 

Palpation  of  iliac  fossae,  psoas  abscess  recognized  by 214 

Paradox  in  treatment  of  joint  disease  and  fracture 106 

Paralysis  of  anterior  muscles  of  thigh,  hyperextension  of  knee  in  .     .     .       35 
Paralysis  of  muscles  of  thigh,  pressure  and  counter-pressure  in     .     .      35,  36 

Paralysis  of  quadriceps  extensor 34 

Paralysis,    recumbency    and    graduated  exercises   in   early   stage   of 

infantile 34 

Paraplegia  of  Pott's  disease 211,212 

Parker  (New  York,  1801-84),  Dr.  Willard 90 

Passive  motion  liable  to  promote  tuberculous  activity 124 

Pasteboard  silhouettes  illustrating  deformity  of  hip  disease    .  165-167 

Pathological  doctrine,  Adams  on  average  life  of 73 

Peg-leg  locomotion  in  talipes  calcaneus 39 

Peg-leg  protection  in  ankle  disease 86 

Pendent  limb  in  knee  disease  and  hip  disease 82,   122 

Perineal  strap  key  to  convenient  use  of  hip  splint,  length  of     .    109,  1 10,  1 19 

Periods  of  rapid  growth,  treatment  to  be  more  urgent  in 2 

Peripheral  axis,  rotation  of  vertebra  on 219,  220,  225 

Perpetual  falling  and  perpetual  recovery  in  locomotion 41,51 

Phantom  tumors  caused  by  rotation 227 

Philipeaux  (Lyon),  Raymond 99,  103 

Philosophy  and  humor  of  Dundreary's  witticism 100 

Physical  demonstration  in  orthopaedic  practice 63,  161 

Physick  (Philadelphia,  1768-1837),  Dr.  Philip  Syng 102 

Plane  dividing  varus  and  valgus 9 

Plaster  in  club-foot  and  hip  disease,  adhesive     .    6-8,  12-14,  92,  113,  114 
Plaster  of  Paris  applied  by  Gibney  to  reduce  flexion  of  knee.  78 

Plaster  of  Paris  in  club-foot 5 

Plaster -of-Paris  jacket 208 

Plastic  dressings  and  forced  extension  in  Pott's  disease  ....       208,  209 

Portable  frame  for  Pott's  disease,  Bradford's 202 

Portable  frame  for  Pott's  disease,  Napier  on 202 

Portable  frame  modified  by  Whitman 202 

Position  in  hip  disease  dictated  by  comfort  and  convenience  .     174,  176,  177 

Position  in  hip  disease  more  important  than  motion 161 

Position  not  determined  by  morbid  anatomy  of  hip-joint       ....     174 

Possession,  tenacity  of  tuberculous 216 

Post  (New  York,  1800-86),  Dr.  Alfred  Charles 90 

Pott  (London,  1714-88),  Mr.  Percivall 212 

Pott's  disease,  Bradford's  portable  frame  for .     202 

Pott's  disease,  details  of  mechanical  treatment  of 206-209 


266  INDEX. 

PAGE 

Pott's  disease,  early  diagnosis  of 189,  190,  196,  197 

Pott's  disease,  forcible  correction  in 206 

Pott's  disease,  growth  facilitating  improvement  of  figure  in    .     .       204,  205 

Pott's  disease,  growth  favoring  recovery  from 191 

Pott's  disease  in  the  aged 191 

Pott's  disease,  insidious  nature  of 190,  197 

Pott's  disease,  lateral  curve  in 189 

Pott's  disease,  leverage  in  treatment  of 203 

Pott's  disease,  local  pain  and  disability  absent  in 197,  198 

Pott's  disease  marked  by  displacement  of  axis  of  head,  cervical  .  194-196 
Pott's  disease,  mechanical  environment  a  factor  in  recovery  from    .     .     201 

Pott's  disease,  mechanical  treatment  promoting  growth  in 210 

Pott's  disease,  nil  desperandiim  in  treatment  of 201 

Pott's  disease,  pain  in  stomach  in 142,  191,  192,  197 

Pott's  disease,  pressure  and  counter -pressure  in  treatment  of  .  .  .  203 
Pott's  disease,  prosthetic  apparatus  for  sitting  position  in  .  .  .  210,211 
Pott's  disease,  redistribution  of  pressure  by  posterior  force  in  .     .       203,  209 

Pott's  disease,  reduction  of  stature  in 210 

Pott's  disease,  unexpected  clinical  features  in 197 

Pott's  disease,  wiring  vertebral  processes  in 208 

Pounding  heel  in  diagnosis  of  hip  disease 151 

Precision  and  exact  science  in  orthopaedic  practice,  methods  of,  63,  73,  163 

Prehension  by  adhesive  plaster  an  American  invention 92 

Preparation  of  vertebral  column  demonstrating  cause  of  rotation    .  221-223 

Present  day,  conservative  surgery  of 67 

Pressure  and  counter-pressure  for  deformity  of  knee  and  of  hip  .  175,176 
Pressure  and  counter-pressure  in  bow-legs  and  knock-knee  ....  80 
Pressure  and  counter -pressure  in  treatment  of  club-foot  .  .  .  .  5,  6,  11 
Pressure  and  counter-pressure  in  paralysis  of  muscles  of  thigh  .  .  35,  36 
Pressure  and  counter -pressure  in  treatment  of  Pott's  disease      .     .     .      203 

Pressure  on  ribs  incompetent  to  reduce  curvature 238 

Prevention  of  ankylosis  by  fixing  joint  and  subduing  inflammation 

68-70,  107 

Preventive  and  therapeutic,  prosthetic  apparatus 60 

Prince  (Jacksonville,  111.,  1816-89),  Dr.  David 127 

Prognosis  in  joint  disease  depending  on  date  of  diagnosis     .     .     .     .70,149 

Projection  of  sternum  produced  by  caries,  anterior 215,216 

Prosthetic  apparatus  for  neglected  club-foot 17 

Prosthetic  apparatus  for  sitting  position  in  Pott's  disease     .     .     .       210,  21 1 

Prosthetic  apparatus  in  Charcot's  knee 53 

Prosthetic  apparatus  preventive  and  therapeutic 60 


INDEX.  267 

PAGE 

Protection  and  fixation  in  treatment  of  white  swelling  of  knee  .     .      74,  85 
Protection  and  traction  in  hip  disease,  comparative  importance  of     .     122 

Protection  by  horseback,  bicycle,  and  tricycle  riding 126 

Protection  by  ischiatic  crutch  promoting  symmetrical  gait .     .     .     .177-179 

Protection  facilitating  return  to  normal  rhythm 177,178 

Protection  from  traumatism  inducing  resolution 122,  123 

Protection  in  ankle  disease  secured  by  peg-leg 86 

Protection  in  hip  disease  by  flexing  knee  in  silicate  bandage   .     .     .     .     126 

Protection  in  joint  disease  of  lower  extremity,  methods  of 125 

Protection  sought  by  the  adoption  of  abnormal  rhythm 177 

Pseudo-hypertrophic  muscular  paralysis,  saddle-back  of 194 

Psoas  abscess  and  contraction  producing  flexion 213 

Psoas  abscess  recognized  by  palpation  of  iliac  fossae 214 

Puerperal  dislocation  of  pelvic  bones,  Goldthwait  on 194 

Pumping  of  joint  by  hip  sphnt 1 19 

Quadriceps  extensor,  paralysis  of 34 

Quadrupedal  gait,  modifications  of 11,184,185 

Quiet  necrosis  of  shoulder,  Paget's  case  of 125 

Quiet  resolution  absent  from  joints  of  lower  extremities  ....       123,124 

Rachitic  deformities,  Blanchard  on  osteoclasis  in 80,  81 

Rachitic  and  paralytic  deformities,  growth  affecting  treatment  of 

51,  52,  79 

Rack  and  pinion  of  hip  splint 106,  114 

Radius  of  disturbance  in  joint  disease 189 

Raphael  (New  York,  1818-80),  Dr.  Benjamin  J 90 

Rapid  growth,  treatment  to  be  more  urgent  in  periods  of 2 

Rare  cases  of  lateral  curvature,  costal  kyphosis  in 236 

Rate  of  growth  in  spondylitics,  H.  L.  Taylor  on 210 

Reaction  and  consoHdation  in  Pott's  disease 205 

Reaction  and  recovery  in  tuberculous  joint  disease 72 

Real  or  structural  and  apparent  shortening  .     .     .     .        147,  170,  171,  180 

Recognition  of  cause  of  rotation  by  Rogers-Harrison 234 

Recognition  of  mechanical  surgery,  Stephen  Smith  on 58 

Recovery  and  perpetual  falling  in  locomotion,  perpetual    ....      41,  51 

Recovery  and  repair  of  tuberculous  joints,  natural 67 

Recovery  certain  in  tuberculous  joint  disease 67,  68,  72 

Recovery  from  infantile  paralysis,  spontaneous 33 

Recovery  from  joint  disease  promoted  by  growth 67,  72 

Recovery  from  Pott's  disease  favored  by  growth 191 


268  INDEX. 

PAGE 

Recovery,  growth  a  factor  in i 

Recovery  of  diseased  knee  favored  by  improved  mechanical  environ- 
ment              74 

Recumbency  and  graduated  exercises  in  infantile  paralysis    ....       34 

Recumbency  and  growth  in  lateral  curvature 239 

Recumbency  in  lateral  curvature,  deformity  reduced  by  .  .  .  239,  240 
Recumbency  in  treatment  of  knock-knee  and  bow-legs       ....      79,  80 

Recumbency  in  treatment  of  Pott's  disease,  Napier  on 202 

Recumbent  child,  muscular  action  a  factor  in  lateral  curvature  of      .  239,  240 

Recurrent  caries  from  overexertion  after  hip  disease 129 

Redistribution  of  intervertebral  pressure  by  posterior  force  .  203,  209,  237 
Reduction  of  congenital  club-foot,  juvenile  growth  facilitating  ...  13 
Reduction  of  deformity  by  pressure  and  counter-pressmre  .     .     .       175,176 

Reduction  of  deformity  of  hip  disease  by  Ridlon 172 

Reduction  of  deformity  of  hip  disease  favored  by  growth  .  .  .  159,  180 
Reduction  of  extreme  deformity,  traction  and  counter-traction  in  .  .  175 
Reduction  of  rotating  curvature  by  recumbency  and  suspension  .       239-241 

Reduction  of  stature  in  Pott's  disease 210 

Reflex  contraction  and  confirmed  by  ankylosis,  fixation  initiated  by  .     .     171 

Reflex  muscular  action  described  by  Davis 172 

Reflex  muscular  action  described  by  Verneuil 143 

Reflex  muscular  action  in  hip  disease,  discovery  of 143,  144 

Reflex  muscular  action  in  hip  disease,  effect  of  .     .       144,149,150,171,172 

Reflex  muscular  action  in  knee  disease 81,  82 

Relapse  to  varus  indicated  by  callus 15 

Relapsed,  inveterate,  and  neglected  club-foot .       16 

Relation  of  joint  diseases  to  the  centre  of  gravity  of  the  body  .     .        100,  loi 

Relaxation  of  straps  of  hip  splint,  causes  of 118,119 

Release  and  fixation  of  jointed  leg  brace 37~39 

Release,  bucket  release  and  lever 38,  39 

Repair  in  hip  disease,  natural 87,  138 

Repair,  rest  and  growth,  Hilton  on 1,4 

Repair,  rest  necessary  to 4 

Repair  the  repetition  of  growth i 

Residuum  of  deformity  and  disability 62 

Resolution  in  lower  extremities  prevented  by  habitual  traumatism  .  .  70 
Resolution  induced  by  protection  from  traumatism  ....  122,  123 
Resolution  of  joint  inflammation  in  upper  extremities  ...        70,  88,  123 

Respiratory  brace,  French's 242 

Rest  in  lateral  curvature,  growth  favoring  effect  of 243,  244 

Rest  in  treatment  of  inflammation 68,  69,  74 


INDEX.  269 

PAGE 

Rest  in  treatment  of  joint  disease,  definition  of 68 

Rest  necessary  for  fiat-feet        . 29 

Rest  necessary  to  repair 4 

Rest,  repair,  and  growth,  Hilton  on i>  4 

Resting  by  sitting  on  hip  splint "3 

Results  after  third  stage  of  hip  disease,  functional 158-160 

Results  of  hip  disease,  growth  affecting i59 

Results  of  hip  disease,  mathematical  appreciation  of    ...     •       160-169 
Retention  at  a  disadvantage  from  short  leverage  at  hip  .     .     -     -       101,102 

Rhythm  an  early  sign  of  hip  disease,  abnormal 142,  180 

Rhythm,  diagrams  of  normal  and  abnormal 185,  186 

Rhythm  easily  modified  during  growth        180,  186,  187 

Rhythm  in  single  congenital  dislocation,  normal 148 

Rhythm,  lameness  produced  by  abnormal  and  concealed  by  normal    .     185 

Rhythm  of  human  locomotion 118,142,148,185-187- 

Ribs,  curvature  of  spine  not  reduced  by  pressure  on 238 

Ribs,  rotation  aggravated  by  lateral  pressure  on 238 

Rickets,  rounded  back  of ^9^ 

Ridlon  (Chicago),  Dr.  John 172 

Riser  and  tread  of  club-foot  brace 10,  48 

Rogers-Harrison  (London,  181 1-90),  Mr.  Charles  Henry 234 

Roller  bandage  replaced  by  laced  legging 112,113 

Romaine  (New  York),  Dr.  De  Witt  Clinton 82 

Ross  (Altona,  1818-61),  Gustav i°3 

Ross  (New  York),  Dr.  WilHam ^49 

Rotating  curvature  illustrated  in  case  of  President  Garfield    .     .       218,219 

Rotating  curvature  in  leopards  and  other  animals 225 

Rotating  curvature,  incidental  and  typical 234,  235 

Rotating  curvature,  unrecognized 225,  226 

Rotation  adding  graceful  sinuosity  to  sigmoid  curve 224 

Rotation  adding  serpentine  element  to  lateral  cxirvature   .     .     .       217,  235 

Rotation  affecting  torso --5 

Rotation  aggravated  by  lateral  pressure  on  ribs 238 

Rotation  and  curvature  inseparable 223 

Rotation,  compensatory 223,  224,  234 

Rotation  demonstrated  by  preparation  of  vertebral  column,  cause  of  221-223 

Rotation  described  by  Dods  in  1824 217 

Rotation  directly  opposed  by  antero-posterior  pressure  ....       237,  238 

Rotation  discovered  by  bimanual  palpation  of  chest 227 

Rotation  independent  of  flexion  and  extension  of  spine     .     .     .       232,  233 
Rotation  on  central,  peripheral,  and  remote  axis 219-221 


270  INDEX, 

PAGE 

Rotation  opposed  by  chest  expansion 243 

Rotation  recognized  by  Rogers-Harrison,  cause  of    ......     .     234 

Rotation  seen  in  gymnasium  and  in  animals 225 

Rotation,  theories  of  cause  of 230-233 

Rotation,  true  theory  of  cause  of 233 

Rotation,  tumors  caused  by 225-227 

Rounded  back  of  rickets  and  spastic  contraction 192 

Rule  for  application  of  spinal  brace 207 

Rule  for  management  of  hip  splint  at  home 119,120 

Ruse  to  escape  painful  examination,  boy's 151 

Rust,  adhesive  plaster  applied  to  prevent 11,36 

Sacro-iliac  disease,  infrequency  of 230 

Saddle-back  of  pseudo-hypertrophic  muscular  paralysis 194 

"Sailor  gait"  of  congenital  dislocation  of  hip 148 

Savarin  (Paris,  1755-1826),  Jean  Anthelme  Brillat 27 

Sayre  (Nevs^  York,  1820-1900),  Dr.  Lewis  Albert  .     .     .     .       90,91,98,229 

Scar  without  preceding  sinus  in  hip  disease 133 

Schapps  (Pony,  Montana),  Dr.  John  Carpenter 59,  60,  86 

Sciatic  scoliosis.  Whitman  on 229 

Sciatica  marked  by  lateral  curve  of  spine 228,  229 

Scoliosis,  curved  line  of  beauty  in 235 

ScoHosis,  kyphosis,  and  lordosis '.193 

Scoliosis,  sciatic 229 

Sculpture,  effect  of  rotation  on  torso  overlooked  in 225 

Semi-tractable  joint 173 

Sequence  of  causes  of  lateral  curvature 244 

Serpentine  effect  of  rotation  in  lateral  curvature    .     .     .     .     .     .     .217,235 

Shaffer  (New  York),  Dr.  Newton  Melman 100,171 

Sherman  (San  Francisco),  Dr.  Harry  Mitchell      ........       66 

Shoe  indicating  relapse  to  varus 15 

Short  hip  splint 92 

Short  leverage  at  hip-joint,  disadvantage  of 101,102,176 

Short  Hmb,  spinal  curvature  reduced  by  factitious  lengthening  of    .     .     181 

Short  tendo  Achillis,  equine  foot  favored  by 184 

Short  tendo  Achillis,  locomotion  not  impaired  by  moderately  .     .     .      21,  46 

Shortening,  fracture  of  longer  bone  to  neutralize 181 

Shortening  neutralized  by  equine  foot 154,  183-185 

Shortening  produced  by  adduction,  apparent   .     161,  162,  165-167,  170,  171 

Shortening  produced  by  disuse  and  overuse 181 

Shortening,  real  or  structural  and  apparent      .     .     .     .      147,170,171,180 


INDEX. 


271 


PAGE 

Shoulder,  Paget  on  quiet  necrosis  of 125 

Shoulder,  vicarious  mobility  in  ankylosis  of 125 

Sigmoid  curve  of  spine 224 

Significance  of  abscesses ixq 

Signs  and  symptoms 142,  162   228 

Silhouettes  illustrating  deformity  of  hip  disease i6:;-i67 

Sinuosity  imparted  to  sigmoid  curve  by  rotation 224 

Sinus  in  hip  disease,  scar  without  a 173 

Sinuses  in  exanthemata,  deportment  of 141 

Sinuses,  effect  of  temporary  closure  of 141 

Sinuses  in  hip  disease,  location  of 135,139,140,153 

Sitting  and  standing,  composite  sensation  of 112,113 

"  Sitting  down,"  boy  wearing  hip  sphnt  thought  he  was 113 

Sitting  position  in  Pott's  disease,  prosthetic  apparatus  for  .     .     .       210,211 

Skeleton  on  outside,  brace  likened  to 54,  207 

Smith  (London),  Mr.  E.  Noble 103,  234 

Smith  (New  York),  Dr.  Stephen 58 

Sole  of  shoe  built  up  on  outer  border  to  oppose  varus 1 1 

Sole  of  shoe  by  steel  in-sole,  protection  of 12 

Sole  of  shoe  with  an  extension  outward  to  oppose  varus 1 1 

Spastic  club-foot,  growth  affecting  treatment  of 16 

Spastic  club-foot,  weight  of  body  in i6 

Spastic  contraction,  rounded  back  of 102 

Specialty,  orthopedic  surgery  as  a 61 

Spinal  brace,  rule  for  management  of 207 

Spinal  landmarks.  Whitman  on ic)2 

SpondyHtics,  H.  L.  Taylor  on  rate  of  growth  in 210 

Spontaneous  dislocation,  Hayward  and  March  on 89 

Spontaneous  opening  of  abscesses 131, 132,  214 

Spontaneous  recovery  from  infantile  paralysis 33 

StabiHty  of  knee  promoted  by  hyperextension 35,84 

Stamping  club-foot  straight 10,  13 

Standing  and  kneeling,  composite  sensation  of 47 

Standing  and  sitting,  composite  sensation  of 112,  113 

Stature  in  Pott's  disease,  reduction  of 210 

Steel,  apparatus  improved  by  introduction  of  Bessemer 3 

Steel  insole,  protection  of  shoe  by 12 

Steele  (St.  Louis),  Dr.  Aaron  John 145 

Stephen  Smith  on  importance  of  mechanical  surgery 58 

Sternum,  anterior  deformity  produced  by  caries  of 215,  216 

Stevens  (New  York,  1 789-1869),  Dr.  Alexander  Hodgdon 90 


272 


INDEX. 


PAGE 

Stomach  pain  in  Pott's  disease 142,191,192,197 

Straight,  stamping  club-foot      .     .     .     . 10,  13 

Strain  on  tendo  Achillis,  demonstration  of 42-46 

Strain  on  tendo  Achillis,  Wirt  on 46 

Stromeyer  (Hanover,  1804-76),  Dr.  Louis 18 

Structural  lengthening,  Broca's  case  of 182 

Structural  shortening,  affections  producing 147,  180,  181 

Structural  shortening  neutrahzed  by  equine  foot  ....  154,  183-185 
Subcutaneous  surgery  introduced  by  Stromeyer,  Little,  and  Detmold  18-21 
Subcutaneous  tenotomy  postponed  by  fear  of  wounding  tendons  ...         3 

Subjective  symptoms  and  objective  signs 142,162,228 

Subluxation  in  knee  disease 82,  85 

Surgery  as  a  specialty,  orthopaedic 61 

Surgery  of  the  present  day,  conservative 67 

Surgery,  recognition  of  mechanical 58 

Suspension,  asthma  relieved  by 242 

Suspension  by  jury-mast  in  Pott's  disease 203,  209 

Suspension,  disappearance  of  lateral  curvature  during 241 

Suspension  in  lateral  curvature,  growth  favoring  effect  of  .     .     .       243,  244 

Suspiration  by  cadaver  after  suspension,  audible 242 

Symmetrical  locomotion  facilitated  by  protection 177-179 

Symmetrical  locomotion,  deformity  prevented  by 177-179 

Symmetrical  walking  replacing  lameness 185,  186 

Symmetry  of  deformed  feet  promoted  by  growth 5,  62 

Symptoms  and  signs 142,  162,  228 

Synovitis,  chronic 7^ 

Synovitis  of  hip-joint  after  typhoid  fever 148 

Systematic  drill  in  acquirement  of  correct  rhythm 187,  188 

Tabetic  talipes  valgus 53 

Table  of  joint  disease  in  upper  and  lower  extremity 123 

Tahpes  of  Friedreich's  disease  and  locomotor  ataxia 53 

Talipes  varus  and  valgus,  mechanics  of  production  of 51 

Taylor  (New  York,  1827-99),  Dr.  Charles  Fayette  .     .     .     .     3,  30,  70,  71, 

91,99,  112,  113,  127 

Taylor  (New  York),  Dr.  Henry  Ling 210 

Temporary  closure  of  sinuses,  effect  of 141 

Tenacity  of  tuberculous  possession 216 

Tendo  Achilhs,  demonstration  of  strain  on 42-46 

Tendo  Achillis,  equine  foot  favored  by  short 184 

Tendo  .'\chillis,  Hibbs  on  effect  of  dividing 46 


INDEX.  273 

PAGE 

Tendo  Achillis  in  club-foot,  division  of 18 

Tendo  Achillis  inevitably  elongated  in  paralysis 40 

Tendo  Achillis,  locomotion  impaired  by  long    .     .  4°,  46 

Tendo  AchilUs,  locomotion  not  impaired  by  moderately  short     .     .     !2i,  46 

Tendons  of  leg,  corner  of  ankle  turned  by 3° 

Tendons  of  leg,  flat-foot  induced  by  constriction  of 29,  30 

Tendons,  tenotomy  postponed  by  fear  of  wounding 3 

Theories  of  cause  of  rotation 230-233 

Theory  of  cause  of  rotation,  true 233 

Therapeutic,  prosthetic  apparatus  preventive  and 60 

Third  stage,  details  of  apphcation  of  hip  splint  in ii5-"7 

Third  stage,  functional  results  of  hip  disease  in 158-160 

Third  stage  of  hip  disease,  Hancock's  description  of  patient  in    .       114,  115 

Third  stage  of  hip  disease,  intelUgent  expectation  in 159 

Third  stage  of  hip  disease,  weight  and  pulley  in 117 

Thomas  (Liverpool,  1833-90),  Mr.  Hugh  Owen      .     .     .     88,99,102,172 

Toe  in  club-foot,  inversion  of 15 

Toe  to  upper  part  of  leg,  weight  transferred  from 12,47 

Toleration  of  mechanical  treatment  by  children 55,  56,  63,  72 

Torso  affected  by  rotation 225 

Townsend  (New  York),  Dr.  Wisner  Robinson 83 

Traction  and  counter -traction  in  reduction  of  extreme  deformity  .     .     .     175 

Traction  and  fixation,  correlation  of 102,  104 

Traction  and  protection  in  hip  disease,  comparative  importance  of       .     122 

Traction  by  adhesive  plaster  an  American  invention 92 

Traction  by  adhesive  plaster  in  hip  disease,  details  of      .     .     .     .      113,114 
Traction  by  weight  and  pulley  or  splint  producing  fixation  .     .     .       104,105 

Traction  discontinued  in  favor  of  ischiatic  support 120,  121 

Traction  formerly  called  extension 89 

Traction  in  hip  disease,  reasons  for  applpng 98 

Traction  \vith  adhesive  plaster  in  hip  disease  by  Davis  and  Sayre  ...       90 

Traction  with  adhesive  plaster  in  fractures 89,  90 

Tragical  illustration  of  rotating  curvature 218,219 

Trapezius  muscle  obscuring  projection  in  cervical  disease 195 

Trauma  and  tuberculous  joint  disease 65 

Traumatism  and  locomotion  inseparable 126 

Traumatism,  inflammation  resolved  by  protection  from  .     70,  88,  122,  123 

Tread  and  riser  of  club-foot  brace 10,  48 

Treatment  of  club-foot  affected  by  weight  of  body    .     .     .       7-9,  14-17,  22 

Treatment  of  hip  disease,  discontinuing 128,129 

Treatment  of  joint  disease  and  fracture,  paradox  in 106 

18 


274  INDEX. 

PAGE 

Treatment  of  knock-knee  and  bow-legs,  growth  affecting 79 

Treatment  of  lateral  curvature  determined  by  clinical  observations  .     .     238 

Treatment  of  Pott's  disease,  nil  desperandum  in 201 

Treatrtient  to  be  more  urgent  in  periods  of  rapid  growth 2 

Tricycle  riding  and  protection .     126 

Trochanter  to  ilio-ischiatic  line,  relation  of 169 

Tropical  gums  in  manufacture  of  adhesive  plaster 75 

True  theory  of  cause  of  rotation 233 

Tuberculous  action  influenced  by  mechanical  environment  .  .  .  62,  123 
Tuberculous  activity  promoted  by  passive  motion  and  hrisement  forc^       1 24 

Tuberculous  deposits,  operative  removal  of 66 

Tuberculous  joint  disease  and  innutrition 64,  65 

Tuberculous  joint  disease  and  trauma 65 

Tuberculous  joint  disease  depending  on  general  reaction,  recovery  from  .  72 
Tuberculous  joint  disease,  intelligent  expectation  in  treatment  of  .  4,  67,  68 
Tuberculous  joint  disease,  mechanical  or  operative  treatment  of    .       65-67 

Tuberculous  joints  certain  to  recover 67,  68,  72 

Tuberculous  joints,  duration  of  treatment  of 7ii72 

Tuberculous  joints,  natural  repair  and  recovery  of  ......     .        67 

Tuberculous  joints,  upper  extremity  comparatively  exempt  from    .     70,  123 

Tuberculous  joints,  weight  of  body  to  be  removed  from 68 

Tuberculous  possession,  tenacity  of 216 

Tumor  in  Gideon  Mantell's  case,  mistaken  diagnosis  of   ....     .     226 

Tumors  caused  by  rotation 225-227 

Twofold  function  of  muscular  system  of  joint 100 

Typhoid  fever  followed  by  synovitis  of  hip-joint 148 

Typical  rotating  or  lateral  curvature 235 


Ultimate  deformity,  juvenile  growth  in  prevention  of 72 

Uncertain  origin,  abscess  of 214,215 

Unconscious  correction  of  deformity  of  hip  disease 178,  179 

Uncorrected  club-feet  useful  in  locomotion 16 

Unexpected  cHnical  features  of  Pott's  disease 197 

Unmistakable  signs  of  advanced  hip  disease 145,  146 

Unrecognized  cases  of  lateral  or  rotating  curvature 225,226 

Untwisting  anterior  part  of  foot  by  strip  of  adhesive  plaster   ....       12 

Ununited  fracture,  ischiatic  crutch  in  treatment  of ,.     .     128 

Upper  extremities,  inflammation  resolved  in  joints  of  .  .  .  70,  88,  123 
Upper  extremities  more  exempt  from  effects  of  infantile  paralysis  .  .  ^t, 
Upper  extremity  comparatively  exempt  from  tuberculous  joints  .     .     70,123 


INDEX.  275 

PAGE 

Value  of  protection  and  traction  in  hip  disease,  comparative     .     .     .     122 

Varix  producing  hyperaemia  and  lengthening,  aneurysmal 182 

Varus  and  valgus  divided  by  boundary  plane ^     .     .     .         9 

Varus  and  valgus,  mechanics  of  production  of  paralytic 51 

Varus,  callus  indicating  relapse  to ■ 15 

Varus,  Cook  on  treatment  of  talipes 11 

Varus  opposed  by  elevating  outer  border  of  sole 11 

Varying  rates  of  growth,  recognition  of 2 

Verneuil  (Paris,  1823-95),  Aristide  Augusta 91,  143 

Vertebra  on  central,  peripheral,  and  remote  axis,  rotation  of  .     .     .219-221 

Vertebral  column  bisecting  cavity  of  chest  and  abdomen 218 

Vertebral  column  demonstrating  cause  of  rotation,  preparation  of       221-223 

Vertebral  processes  in  Pott's  disease,  wiring 208 

Vicarious  mobility  in  ankylosis  of  shoulder  and  of  hip  ....       125,  161 

Vicious  circle  in  joint  disease         93 

Vigilance  niusculaire,  Verneuil  on 143 

Violence  visiting  joints  of  lower  extremity  in  locomotion     .     .    123,  124,  126 

Visceral  degeneration  and  abscesses 139 

Vision  in  horizontal  plane  preserved  by  extension  of  head  .     .     .       194,  195 
Vital  conduits  converging  at  base  of  neck 212 

Wadding,  cushions,  and  pads  not  necessary  in  apparatus       ....       54 

Watson  (New  York,  1807-63),  Dr.  John 90,  103 

Weight  and  pulley  applied  by  Brodie  in  hip  disease 90,  99 

Weight  and  pulley  demonstrated,  production  of  fixation  by     .     .      104,  105 

Weight  and  pulley  in  hip  disease,  Liston  on 99 

Weight  and  pulley  in  third  stage  of  hip  disease 117 

Weight  and  pulley  producing  fixation  in  "Buck's  extension"  ....     105 
Weight  and  pulley  reducing  deformity  of  hip  disease    .     .     .     .       117,  172 

Weight-bearing  facilitated  by  hyperextension  of  knee 3S>  84 

Weight  of  body  affecting  treatment  of  club-foot      ....       7-9,14-17,22 

Weight  of  body  as  a  factor  of  joint  disease 123 

Weight  of  body  to  be  removed  from  diseased  knee  and  hip    .     .     .      74,  87 

Weight  of  body  to  be  removed  from  tuberculous  joints 68 

Weight  of  body  to  be  removed  in  coxa  vara 148 

Weight  of  body  to  be  removed  in  knock -knee  and  bow-legs    ...      79,  80 

Weight  of  body  to  be  thrown  on  heel  in  flat-foot 30 

Weight  thrown  on  ischium  in  artificial  limb 126 

Weight  transferred  from  toe  to  upper  part  of  leg 12,  47,  49 

"Wheel,  the  human" 41 


276  INDEX. 

PAGE 

White  swelling  of  knee  by  Romaine,  early  recognition  of 82 

White  swelling  of  knee,  early  diagnosis  of 81,  82 

White  swelling  of  knee  formerly  requiring  amputation  ....  82,  83,  137 

White  swelling  of  knee,  home  management  of 85,  86 

White  swelhng  of  knee,  hyperextension  in 77,  83-85 

White  swelling  of  knee,  ischiatic  crutch  in  treatment  of 81 

White  swelling  of  knee,  protection  and  fixation  in  treatment  of  .     .      74,  85 

Whitman  (New  York),  Dr.  Royal 192,  202,  209 

Willard  (Philadelphia),  Dr.  De  Forest 5 

Window  in  club-foot  brace  for  exit  of  adhesive  strip 13 

Wiring  vertebral  processes  in  Pott's  disease 208 

Wirt  (Cleveland),  Dr.  Wilham  Edgar 46 

Wood  (New  York,  1817-82),  Dr.  James  Rushmore 90 

Wooden  high  sole  for  well  foot no 

Wounding  tendons,  tenotomy  postponed  by  fear  of 3 

Wrist  disease,  treatment  of  abscess  of 124 

Wry-neck  of  cervical  Pott's  disease 194 

Wyeth  (New  York),  Dr.  John  Allen 100 

Yale  (New  York),  Dr.  Leroy  Milton 99 

Young  (Philadelphia),  Dr.  James  Kelly 196 

Zinc  oxide  replaced  by  India-rubber  in  adhesive  plaster    .....       75 


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The  influence  of  growth  on  congenital  an 


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